
Class. 
Book 



COPYRIGHT DEPOSIT 



MODERN MEDICINE 



BY 



JULIUS L. SALINGER, M.D. 

DEMONSTRATOR OF CLINICAL MEDICINE, JEFFERSON MEDICAL COLLEGE; CHIEF OF THE 

MEDICAL CLINIC, JEFFERSON MEDICAL COLLEGE HOSPITAL; ATTENDING 

PHYSICIAN TO' THE PHILADELPHIA HOSPITAL 



FREDERICK J. KALTEYER, M.D. 

ASSISTANT DEMONSTRATOR OF CLINICAL MEDICINE, JEFFERSON MEDICAL COLLEGE ; HEMA- 

TOLOGIST TO THE JEFFERSON MEDICAL COLLEGE HOSPITAL,' PATHOLOGIST TO 

THE LYING-IN CHARITY HOSPITAL, PHILADELPHIA; ASSISTANT 

PATHOLOGIST TO THE PHILADELPHIA HOSPITAL 



ILLUSTRATED 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS & COMPANY 
1900 



60153 



1-Jbrw? of CongisMB 

OCT 12 1900 
SECOND COPY. 

OCT 16 1900 



T^ G 



Copyright, 1900, 
By W. B. SAUNDERS & COMPANY 



PRESS OF 

B. SAUNDERS Si. COMPANY 



LC Control Number 




tmp96 028666 



TO 
OUR FRIEND AND TEACHER, 

JAMES C. WILSON, A.M., M.D., 

PROFESSOR OF THE PRACTICE OF MEDICINE AND CLINICAL MEDICINE 

IN 
THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA, 

THIS WORK IS DEDICATED. 



PREFACE. 



In the present era the practice of medicine includes the 
study of a number of specialties, such as physical diagnosis, 
bacteriology, the examination of the gastric contents, the urine, 
the blood, the feces, etc. Hence it has frequently been neces- 
sary for the student to procure separate books upon these 
topics. For this reason it has appeared advisable for the 
authors to combine in one volume, as far as possible, the 
essentials of these branches as applied to Clinical Medicine. 

The arrangement of the special topics has been adopted to 
prevent repetition, to present as concise a description of allied 
subjects as possible, and to link more closely the various divi- 
sions.* Thus, the pathogenic germ of a special disease is 
considered under the head of Clinical Bacteriology, rendering 
it unnecessary for one already acquainted with such facts to 
again read the morphology, the biology, the pathogenesis, etc., 
when dealing with the description of the disease. But if 
the reader is unfamiliar with the subject, such facts will be 
found in the section that deals with the micro-organisms that 
are of importance in clinical medicine. 

A similar course has been followed in regard to physical 
diagnosis, examination of the sputum, of the stomach contents, 
of the blood, of the urine, and of the feces. The aim of the 
authors has been to give the main facts in regard to etiology, 
pathology, symptomatology, diagnosis, prognosis, and treat- 
ment as considered from a modern and generally accepted 
standpoint. The most modern medical works in English, 
German, and French have been freely consulted. The authors 
desire to express their thanks to Mr. Thomas F. Dagney, of 
W. B. Saunders & Co., for many courtesies extended during 
the progress of the work. 

Philadelphia, September, igoo. 



CONTENTS. 



PAGE 

SYMPTOMATOLOGY AND SEMEIOLOGY 17 

Examination of the Surface of the Body, 19. — Constitutional Pecu- 
liarities, 20. — The Decubitus, 21. — The Facies, 22. — Consciousness, 
22. — Temperature, 23. — Examination of the Skin, 26. — Eruptions 
(Exanthemata), 33. — Edema, 34. — Emphysema of the Skin, 35. — 
Moisture of the Skin, 36. — The Pulse, 37. — Sphygmography of the 
Radial Pulse, 43. 

PHYSICAL DIAGNOSIS 49 

Examination of the Respiratory Organs, 49. — Physical Diagnosis of 
the Heart, 77. — Examination of the Arterial System, 91. — Examina- 
tion of the Abdominal Organs, 92. 

CLINICAL BACTERIOLOGY 100 

LABORATORY METHODS 122 

Examination of the Sputum, 122. — Examination of the Stomach- 
contents, 128. — Examination of the Blood, 133. — Examination of the 
Urine, 151. — Examination of the Feces, 166. 



PART I.— INFECTIOUS DISEASES. 

The Continued Fevers 17 1 

Simple Continued Fever iyi 



Influenza 



172 



Enteric or Typhoid Fever jys 

Typhus Fever jg6 

Relapsing Fever loo 

Yellow Fever 102 

T>engue Ig5 

Periodic Fevers !o6 

Malaria !g6 

Estivo-autumnal Type 202 

Exanthemata or Eruptive Fevers 204 

Scarlet Fever 204 

Measles 210 

Rubella 212 

Variola (Smallpox) . . ... 213 

Varioloid, or Variola Modificata 217 

Vaccinia (Cowpox) 219 

Varicella 223 

Erysipelas 224 

7 



CONTENTS. 



PAGE 

Fevers with Marked Local Manifestations 228 

Croupous Pneumonia 228 

Acute Rheumatic Fever . ......... 238 

Diphtheria 242 

Cerebrospinal Fever . 248 

Cholera 252 

Plague 257 

Pertussis 259 

Parotitis 261 

Infections without Special Classification . . 262 

Tuberculosis 262 

Acute Miliary Tuberculosis 265 

Tuberculosis of the Lungs 268 

Acute Pneumonic Phthisis 268 

Chronic Ulcerative Tuberculosis 270 

Fibroid Phthisis 275 

Tuberculosis of the Lymph-glands 276 

Tuberculosis of the Serous Membranes 277 

Tuberculosis of the Alimentary Canal 278 

Tuberculosis of the Tongue 279 

Tuberculosis of the Stomach 279 

Tuberculosis of the Intestines 279 

Tuberculosis of the Liver and Pancreas 280 

Tuberculosis of the Genito-urinary System 280 

Tuberculosis of the Kidney 280 

Tuberculosis of the Mammary Gland 281 

Tuberculosis of the Brain and Cord 281 

Tuberculosis of the Arteries and Heart . 281 

Septicemia . 283 

Pyemia 285 

Anthrax 286 

Actinomycosis 287 

Miliary Fever 288 

Mountain Fever 290 

Milk-sickness 290 

Leprosy 291 

Dysentery 295 

Acute Catarrhal Dysentery . 296 

Diphtheric Dysentery 296 

Amebic (or Tropic) Dysentery 298 

Secondary Dysentery 299 

Syphilis , 300 

Acquired Syphilis 301 

Congenital Syphilis 303 

Visceral Syphilis 304 

Glanders 304 

Foot-and-mouth Disease 306 

Hydrophobia 307 

Tetanus 309 

Weil's Disease ". 310 

Malta Fever . ' 31 1 

PART II.— DISEASES OF THE CIRCULATION. 

Congenital Malformations of the Heart 313 

Diseases of the Pericardium 314 

Pericarditis 314 

Acute- Pericarditis 3*4 



CONTENTS. 9 

PAGE 

Diseases of the Pericardium (continued) : 

Suppurative Pericarditis 318 

Chronic Pericarditis 318 

Hydropericardium 321 

Hemopericardium . , 322 

Pneumopericardium 322 

New Growths and Parasites of the Pericardium 323 

Acute Endocarditis 323 

Simple Acute Endocarditis 324 

Infective Endocarditis 327 

Chronic Endocarditis. — Sclerotic Endocarditis. — Mitral Insufficiency . . 330 

Mitral Stenosis 332 

Aortic Insufficiency 334 

Aortic Stenosis 336 

Tricuspid Insufficiency 338 

Tricuspid Stenosis 339 

Pulmonary Incompetence 339 

Pulmonary Stenosis 340 

Combined Valvular Lesions 342 

Effects of Valvular Disease 342 

Hypertrophy of the Heart " . 344 

Dilatation of the Heart 347 

Acute or Simple Dilatation 347 

Chronic Dilatation 348 

Diseases of the Myocardium 350 

Fatty Infiltration . . 350 

Parenchymatous Degeneration 351 

Fatty Degeneration 351 

Acute Myocarditis 352 

Chronic Interstitial Myocarditis 353 

Amyloid Disease 353 

Aneurysm of the Heart 354 

Rupture of the Heart . 355 

New Growths and Parasites 355 

Neuroses of the Heart 356 

Arrhythmia 356 

Palpitation 356 

Irritable Heart 357 

Tachycardia 358 

Bradycardia or Brachycardia 358 

Angina Pectoris 359 

Diseases of the Arteries 361 

Infiltrations and Degenerations 361 

Arteritis, or Inflammation of the Arteries 361 

Acute Arteritis : . 361 

Arteriosclerosis 362 

Aneurysm ... 365 

Aneurysm of the Abdominal Aorta 369 



PART III.— DISEASES OF THE RESPIRATORY SYSTEM. 

Diseases of the Nose . . 370 

Acute Rhinitis 370 

Chronic Rhinitis 371 

Diseases of the Larynx 372 

Acute Laryngitis 372 

Chronic Laryngitis 372 



I O CONTENTS. 



PAGK 

Diseases of the Larynx (continued): 

Edema of the Larynx 373 

Laryngismus Stridulus 374 

Spasm of the Larynx in Children 374 

Spasm of the Larynx in Adults 375 

Cr o u P 375 

Diseases of the Bronchi 376 

Bronchitis 376 

Simple Acute Bronchitis 376 

Fibrinous Bronchitis 379 

Chronic Bronchitis 380 

Bronchiectasis 383 

Bronchial Asthma 386 

Hay-fever 388 

Diseases of the Pulmonary Structure 390 

Pseudohypertrophic Emphysema 390 

Vesicular Emphysema , 390 

Pulmonary Atelectasis 392 

Atelectasis of the New-born 393 

Acquired Atelectasis 393 

Pulmonary Hemorrhage 394 

Bronchopneumonia 397 

Chronic Fibroid Pneumonia 401 

Congestion of the Lungs 403 

Pulmonary Edema 404 

Gangrene of the Lung 405 

Abscess of the Lung 405 

Pneumonokoniosis . 406 

Syphilis of the Lungs 407 

New Growths of the Lungs 409 

Parasites 410 

Diseases of the Pleura 410 

Pleurisy 410 

Dry, Fibrinous, or Plastic Pleurisy 410 

Serofibrinous Pleurisy - 412 

Atypical Forms 416 

Purulent Pleurisy ; Empyema 416 

Special Varieties of Pleurisy 419 

Chronic Pleurisy 424 

Pneumothorax 425 

Hydrothorax 427 

Hemothorax 428 

Tumors of the Pleura 429 

Echinococcus of the Pleura 430 

Diseases of the Mediastinum 430 

Inflammation of the Mediastinum 430 

Abscess of the Mediastinum 431 

Tumors of the Mediastinum 432 

Benign Tumors 432 

Malignant Tumors 433 



PART IV.— DISEASES OF THE DIGESTIVE TRACT. 

Diseases of the Mouth 434 

Catarrhal Stomatitis 434 

Ulcerative Stomatitis 435 

Aphthous Stomatitis . 435 



CONTENTS. I I 



PAGE 

Diseases of the Mouth (continued): 

Parasitic Stomatitis 436 

Mercurial Stomatitis 437 

Gangrenous Stomatitis 438 

Diseases of the Tongue 439 

Acute Glossitis 439 

Chronic Glossitis 439 

Diseases of the Salivary Glands 440 

Hypersecretion 440 

Xerostoma , 440 

Inflammations of the Salivary Glands 440 

Diseases of the Tonsils 441 

Acute Tonsillitis 441 

Acute Follicular Tonsillitis 441 

Suppurative Tonsillitis 443 

Chronic Tonsillitis . 444 

Diseases of the Pharynx 445 

Acute Pharyngitis '.' 445 

Chronic Pharyngitis 440 

Retropharyngeal Abscess 446 

Diseases of the Esophagus ............ . .-~ 447 

Acute Esophagitis 447 

Chronic Esophagitis . 448 

Spasm of the Esophagus . . , 448 

Stricture of the Esophagus 449 

Tumors of the Esophagus 450 

Dilatation of the Esophagus 451 

Rupture of the Esophagus 451 

Diseases of the Stomach 452 

Gastritis 452 

Simple Acute Gastritis 452 

Severe Acute and Toxic Gastritis 453 

Phlegmonous Gastritis 455 

Chronic Gastritis 456 

Dyspepsia 458 

Ulcer of the Stomach 459 

Malignant Tumors of the Stomach . . 465 

Carcinoma 465 

Sarcoma 469 

Nonmalignant Tumors of the Stomach 470 

Foreign Bodies in the Stomach 470 

Hemorrhage from the Stomach 470 

Dilatation of the Stomach, Displacements of the Stomach, and Other 

Deformities 471 

Gastrectasis . . . . 471 

Gastroptosis 473 

Other Displacements 474 

Neurosis of the Stomach 474 

Gastralgia 474 

Bulimia 474 

Neurosis of Secretion 474 

Peristaltic Unrest of the Stomach 475 

Diminished Peristalsis of the Stomach, or Atony 475 

Diseases of the Intestines 475 

Intestinal Catarrh ... 475 

Acute and Chronic Catarrhal Enteritis 475 

Croupous Enteritis 479 

Phlegmonous Enteritis 479 



1 2 CONTENTS. 



PAGE 

Diseases of the Intestines (continued): 

Enteritis of Children 480 

Acute Dyspeptic Diarrhea 480 

Cholera Infantum 481 

Acute Enterocolitis 481 

Mucous Enteritis 482 

Intestinal Ulceration 483 

Cholera Morbus 484 

Enterorrhagia . . . '. 485 

Enteroptosis 486 

Appendicitis ... . 487 

Chronic Appendicitis 493 

Relapsing Appendicitis . . 493 

Intestinal Obstruction 495 

Intussusception of the Bowels 498 

Hemorrhoids 500 

Tumors of the Intestines 501 

Benign Tumors 501 

Malignant Tumors 502 

Diseases of the Peritoneum 504 

Acute Peritonitis 504 

Acute General Peritonitis , 504 

Acute Local Peritonitis 508 

Chronic Peritonitis (Adhesive Peritonitis) 508 

Ascites 510 

Tumors of the Peritoneum 512 

Benign Tumors 512 

Malignant Tumors 512 

Cysts of the Peritoneum . 514 

Diseases of the Liver 515 

Displacements of the Liver 515 

Active Congestion of the Liver 515 

Passive Congestion of the Liver 517 

Fatty Liver 518 

Amyloid Disease of the Liver 520 

Atrophic Cirrhosis of the Liver 521 

Biliary Cirrhosis 525 

Congestion Cirrhosis . . , . 525 

Cirrhosis due to Malaria 526 

Syphilitic Cirrhosis 526 

Hypertrophic Cirrhosis 527 

Acute Yellow Atrophy of the Liver . 529 

Abscess of the Liver 531 

Benign Tumors of the Liver 534 

Malignant Tumors of the Liver 535 

Diseases of the Biliary Passages . , 538 

Obstructive Jaundice 538 

Toxemic Jaundice 53^ 

Catarrhal Jaundice 53^ 

Icterus Neonatorum 539 

Suppurative Cholangitis 54° 

Cholelithiasis; Gall-stones 54 1 

Diseases of the Hepatic Vessels 546 

Diseases of the Portal Vein 546 

Inflammation of the Portal Vein. — Pylephlebitis 547 

Acute Pylephlebitis 547 

Chronic Pylephlebitis ' 54^ 

Diseases of the Pancreas , 549 



CONTENTS. 1 3 

PAGE 

Diseases of the Pancreas (continued) : 

Inflammation of the Pancreas 549 

Acute Hemorrhagic Pancreatitis .*..... 549 

Purulent Pancreatitis (Abscess of the Pancreas) 549 

Gangrenous Pancreatitis 550 

Chronic Indurative Pancreatitis 551 

Tumors of the Pancreas 551 

Benign Tumors . . ' 551 

Malignant Tumors 552 

Pancreatic Cysts 552 

Pancreatic Calculi 553 

Hemorrhage into the Pancreas ' 553 

Fat Necrosis of the Pancreas 554 

Rupture of the Pancreas 555 



PART V.— DISEASES OF THE KIDNEYS. 

Acute Congestion - . . . 556 

Passive Congestion 55^ 

Acute Diffuse Nephritis 558 

Chronic Diffuse Parenchymatous Nephritis 562 

Chronic Interstitial Nephritis . 568 

Amyloid Disease of the Kidney 571 

Suppurative Nephritis 572 

Perinephritic Abscess 576 

Fatty Degeneration and Fatty Infiltration of the Kidney 576 

Pyelitis and Pyelonephritis 576 

Hydronephrosis , 579 

Tumors of the Kidney . 580 

Benign Tumors 580 

Malignant Tumors 580 

Cysts of the Kidney 582 

Malformations and Malposition of the Kidney 582 

Malformations 582 

Floating Kidney . . 583 

Renal Calculi 583 

Uremia 587 



PART VI.— CONSTITUTIONAL DISEASES. 

Diabetes Mellitus 590 

Diabetes Insipidus 595 

Chronic Rheumatism 597 

Gonorrheal Arthritis 598 

Muscular Rheumatism 599 

Rickets 600 

Arthritis Deformans 602 

Gout 604 

Lithemia 607 

Obesity 609 

Osteomalacia 610 

Pulmonary Hypertrophic Osteoarthropathy 610 

Osteitis Deformans 61 1 



14 CONTENTS. 



PART VII.— DISEASES OF THE BLOOD AND OF THE 
DUCTLESS GLANDS. 

PAGE 

Anemia . . 612 

Secondary Anemia 612 

Chlorosis 617 

Pernicious Anemia 619 

Leukemia 621 

Hodgkin's Disease 625 

Splenic Anemia 629 

Addison's Disease 630 

Scurvy , 633 

Infantile Scurvy 635 

Purpura 636 

Symptomatic Purpura 636 

Arthritic Purpura 637 

Purpura Hsemorrhagica 637 

Hemophilia 638 

Myxedema 640 

Adult Myxedema 640 

Sporadic Cretinism 642 

Operative Myxedema 642 

Exophthalmic Goiter . 643 

Acromegaly 645 



PART VIII.— DISEASES OF THE NERVOUS SYSTEM. 

Diseases of the Nerves 647 

Neuritis 647 

Localized Neuritis 647 

Brachial Neuritis 648 

Sciatica . 649 

Multiple Neuritis 650 

Endemic Neuritis . 653 

Diseases of the Cranial Nerves 654 

Diseases of the Olfactory Nerve 654 

• Diseases of the Optic Nerve 654 

Optic Neuritis 654 

Paralysis of the Ocular Nerves 655 

Diseases of the Fifth Nerve (Trifacial) 655 

Diseases of the Seventh Nerve (Facial Paralysis; Bell's Palsy) . . . 656 

Diseases of the Auditory Nerve 657 

Diseases of the Glossopharyngeal Nerve 657 

Diseases of the Pneumogastric or Vagus Nerve 657 

Diseases of the Spinal Accessory Nerve - 658 

Diseases of the Hypoglossal Nerve 658 

Neuralgia 658 

Diseases of the Spinal Cord 660 

Acute Spinal Meningitis . . . 660 

Chronic Spinal Meningitis 662 

Hypertrophic Cervical Pachymeningitis 663 

Hemorrhage into the Spinal Membranes 664 

Anemia and Hyperemia of the Spinal Cord ....'. 666 

Paralysis from Lessened Atmospheric Pressure 1 666 

Hemorrhage into the Spinal Cord 667 



CONTENTS. I 5 

PAGii 

Diseases of the Spinal Cord (continued) : 

Acute Anterior Poliomyelitis 668 

Acute Myelitis 670 

Disseminated Myelitis 672 

Chronic Myelitis 673 

Acute Ascending Paralysis 675 

Locomotor Ataxia 676 

Primary Lateral Sclerosis 680 

Posterolateral Spinal Sclerosis 681 

Putnam and Dana's Combined Sclerosis of the Lateral and Posterior 

Columns 682 

Pellagra 683 

Hereditary Ataxic Paraplegia 683 

Amyotrophic Lateral Sclerosis 684 

Hereditary or Infantile Forms of Progressive Atrophy of Spinal Origin 685 

Progressive Muscular Atrophy of the Heubner-Striimpell Variety . . . 686 

Disseminated Sclerosis 686 

Tumors of the Spinal Cord 688 

Syringomyelia 688 

Diseases of the Medulla and Pons 690 

Progressive Bulbar Paralysis ". . . 690 

Hemorrhage into the Medulla and Pons 691 

Diseases of the Brain 692 

External Pachymeningitis 692 

Internal Pachymeningitis 692 

Acute Leptomeningitis 693 

Chronic Leptomeningitis 694 

Cerebral Hemorrhage 695 

Thrombosis and Embolism 699 

Cerebral Aneurysms 701 

Abscess of the Brain 702 

Encephalitis 703 

Hydrocephalus , 704 

Tumors of the Brain 705 

Cerebral Palsies of Children 709 

Birth Palsy . 709 

Infantile Hemiplegia . . .' 710 

General and Functional Diseases of the Nervous System . 711 

Epilepsy 711 

Jacksonian Epilepsy 715 

Infantile Convulsions 715 

Chorea 716 

Choreiform Affections 718 

Spasmodic Tics 718 

Hereditary Chorea, or Huntingdon's Chorea 719 

Migraine 720 

Paralysis Agitans 721 

Facial Hemiatrophy - 722 

Acute Circumscribed Edema 723 

Raynaud's Disease 724 

Erythromelalgia 725 

Meniere's Disease 726 

Occupation Neurosis 727 

Hysteria 728 

Neurasthenia 733 



1 6 CONTENTS. 



PART IX.— DISEASES OF THE MUSCLES. 

PAGE 

Myositis V 736 

Acute Polymyositis 736 

Myositis Ossificans 737 

Myotonia Congenita 737 

Idiopathic Muscular Atrophy and Hypertrophy 738 

Pseudohypertrophic Muscular Paralysis 739 

Juvenile Form of Progressive Muscular Atrophy 740 

Facioscapulohumeral Form 740 



PART X.— INTOXICATIONS AND SUNSTROKE. 

Poisoning by Food ; Ptomain-poisoning , . 742 

Grain-poisoning 743 

Mushroom-poisoning 745 

Snake Poison 745 

Acute Alcoholism 747 

Chronic Alcoholism 748 

Delirium Tremens 749 

Metal Poisoning 751 

Phosphorus 751 

Chronic Phosphorus-poisoning 752 

Coal-gas and Water-gas Poisoning 75 2 

Chronic Lead-poisoning 753 

Lead Encephalopathy 755 

Chronic Mercurial Poisoning 756 

Chronic Arsenical Poisoning . . 757 

Chronic Silver Poisoning 758 

Sunstroke „„■... 758 

Heat Exhaustion 759 



PART XL— DISEASES DUE TO ANIMAL PARASITES. 

Protozoa 761 

Worms 763 

Flat-worms „ 763 

Round-worms 768 



INDEX 773 



MODERN MEDICINE 



SYMPTOMATOLOGY AND SEMEIOLOGY* 

The science of medicine consists of a great number of 
specific facts, systematized and related to various sciences not 
necessarily pertaining- to the healing art, such as biology, 
physiology, hygiene, etc. 

Biology is the science of living things and the knowledge 
of vital phenomena. 

Physiology pertains to the relations and functions of organ- 
ized bodies, particularly the human body, to the functions of 
organs, and to other vital phenomena. 

Hygiene is that science that treats of the laws of health. 

Prophylaxis is the science that treats of prevention of dis- 
ease. 

Etiology has for its purpose the knowledge of the causation 
of disease. 

Pathology treats of the causes and phenomena of disease. 

Health is that condition of the living organism and of its 
various parts and functions that conduces to efficient and 
prolonged life. 

" Disease is the perturbation of the normal activities of the 
living body" (Huxley). 

In disease the functions alone may be deranged, such as 
palpitation of the heart, nausea, neuralgia ; or functions and 
structures may both be deranged, such as in valvular disease 
of the heart and in croupous pneumonia ; or the structure 
alone may be deranged, as in the formation of atheromatous 
ulcers, thrombi, and emboli. 

Diseases are thus divided into functional and organic, 
although pathologically it is difficult to conceive of deranged 
function without some change in structure. Clinically, how- 
ever, this classification must still be adhered to. 
2 17 



1 8 SYMPTOMATOLOGY AND SEMEIOLOGY. 

The field of medicine is divided into many branches, termed 
specialties, and as our knowledge of disease grows broader 
the limitations between the specialties become narrower ; hence 
they are only provisional and not permanent. 

The specialty with which this work is concerned is termed 
clinical or internal medicine. We recognize disease by two 
sets of phenomena, known as symptoms and signs. The 
organization and classification of symptoms is called symp= 
tomatology. The organization and classification of signs is 
termed semeiology. The symptoms are broadly divided as the 
subjective phenomena — something of which the patient com- 
plains, such as pain, nausea, vertigo. 

The signs may be defined as objective phenomena — some- 
thing which the physician must determine for himself, as the 
cardiac murmur, the crepitant rale, dullness on percussion. 

As signs depend upon the application of the special senses 
by special methods employed for detecting disease during life, 
by anatomic changes which they produce, they are known as 
physical signs, and the method employed is called physical 
diagnosis. 

The science of the classification of disease is termed nosology. 
Diseases may be divided into general and local. General dis- 
eases may be subdivided into infective and diathetic, etc. Local 
diseases relate to particular organs or tissues. 

A further classification, as has previously been intimated, 
consists of functional and organic. 

Disease may be hereditary, acquired, or congenital ; specific 
or nonspecific ; and, as regards its onset or course, acute, sub- 
acute, or chronic. Further important division relates to the 
character of the disease ; hence a disease may be sporadic, en- 
demic, epidemic, or pandemic. 

A sporadic disease is one occurring singly or apart in a 
given locality. Examples of this form are outbreaks of cere- 
brospinal fever, diphtheria, etc. 

An endemic disease is one which is always present in a 
certain community : as, for example, enteric fever in Philadel- 
phia and vicinity ; cholera in the delta of the Ganges. 

An epidemic disease is one which affects a whole people or 
the greater number in a community. Examples of such dis- 
eases are measles, chickenpox, smallpox, etc. 

A pandemic disease is one which affects all people in all 
parts of the world. Influenza is a striking example of the 
pandemic diseases. 



EXAMINATION OF THE SURFACE OF THE BODY. 1 9 



EXAMINATION OF THE SURFACE OF THE BODY. 

Changes in Size and Shape. — In a number of diseases the 
general weight of the body becomes diminished ; in some few, 
an increase takes place. When there is wasting of the entire 
body, we speak of emaciation or general atrophy, but when 
only portions of the body are affected, the condition is spoken 
of as local atrophy. 

In emaciation the most marked sign is wasting of the 
subcutaneous fat. Muscle wasting also occurs in quite a 
number of diseases. Local atrophy depends chiefly upon the 
loss of muscular tissue, but the osseous and other portions 
may also be involved. 

Emaciation. — This can be determined by the ease with 
which a fold of skin can be picked up from the parts beneath. 
When accurate observance is necessary, the scales should be 
employed, and in all diseases in which this occurs, the patient 
should be weighed at regular intervals to determine the prog- 
ress of the malady. The condition is found in the acute 
febrile diseases and in many chronic maladies. It takes place 
in enteric fever, pulmonary tuberculosis, rickets, and congenital 
syphilis. In children loss of weight is more rapid, but is also 
more quickly regained. In females great loss of weight may 
take place in hysteria and allied conditions. It is also a 
symptom of malignant disease, especially of internal organs. 

Local Atrophy. — Atrophy of the skin or muscles may 
occur separately, or they may be jointly involved. The 
atrophy of the skin may result from great stretching during 
pregnancy, known as the lineae albicantes. Atrophy of the 
hands and legs may result from lesions of the nerves or from 
destruction of the cells in the spinal cord. Atrophy of muscle 
may result from four causes : thus, atrophy from disuse ; 
atrophy from disease of the muscles — so-called " myopathic 
atrophy" ; atrophy from diseases of the nervous system, such 
as bulbar paralysis, and atrophy from disease of the joints 
(arthritic atrophy). 

Obesity, — Obesity is a condition in which an excessive 
quantity of fat is present. This occurs commonly in women 
at the climacteric period. It is found in persons who indulge 
freely in malt liquors. It takes place in various forms of 
chronic cerebral disease and diabetes. 

Dropsy is an accumulation of serous fluid in the areolar or 
serous cavities of the body. When the condition is general, 



20 SYMPTOMATOLOGY AND SEMEIOLOGY. 

it is known as anasarca; when it is less marked or local, 
it is spoken of as edema. It increases the size of the part in 
which it occurs, and influences the weight in a peculiar manner. 
The swelling is distinguished by pitting upon pressure with 
the finger. This may be so great as to render the skin tense 
and shiny, or may be scarcely perceptible. It is most marked 
in the dependent parts and in the region in which there is 
much loose cellular tissue, as in the scrotum and eyelids. It 
may occur from any cause interfering with the circulation of 
the blood, or in conditions in which the blood is apt to dete- 
riorate. Generally speaking, it is due to disease of the heart, 
kidneys, or liver. Renal dropsy shows itself often in the face 
and beneath the eyes, spreading downward, and may lead to 
anasarca. Cardiac dropsy shows itself particularly in the feet 
and about the ankles. Dropsy in this condition is also often 
due to anemia, occasionally from obstruction of the pulmonary 
circulation, as in emphysema. In females it may be due to 
varicose veins. Dropsy limited to the peritoneal cavity is 
spoken of as ascites. It is often due to obstruction of the 
portal circulation, occurring particularly in disease of the liver. 
Edema limited to the arms and upper part of the body shows 
mechanical obstruction in the thorax, as from mediastinal 
tumor pressing upon the superior vena cava. Edema limited to 
one leg shows obstruction of one of the veins, as in phlebitis. 
Edema may be due to changes in the blood-vessel walls, as 
in mechanical injury of a part or in inflammation ; and, lastly, 
from disturbance of the lymphatic system. 

CONSTITUTIONAL PECULIARITIES. 

The constitution of the patient depends largely upon three 
conditions : the osseous system, the muscles, and the adipose 
tissue. Depending upon the development of these three con- 
ditions, the person is spoken of as having a strong or a weak 
constitution. 

The habitus of the patient and cachexia sometimes depend 
upon constitutional changes. 

The scrofulous cachexia occurs in children, and the pecu- 
liar expression of the face, the lips, the prominent form of the 
nose, and the swelling of the lymphatic glands about the neck 
and lower jaw, are characteristic. 

Phthisical cachexia depends upon the development of the 
entire body, particularly the chest. The face is thin, the eyes 



THE DECUBITUS. 21 

sparkle, the teeth have a bluish-white appearance, and the 
chest shows the peculiar " expiratory form." This is also 
known as the phthisoid, alar, or pterygoid chest. The chest 
is long and narrow. The interspaces are vertical, and the 
costal angle is more nearly acute. The clavicles are promi- 
nent, the scapulae stand out like wings, giving the name alar 
or pterygoid, and the entire chest shows marked emaciation. 
In this cachexia the finger-tips and the lips are often cyanotic, 
and the fingers show the peculiar deformity known as 
"clubbed finger-tips." The hair upon the head is at first 
well developed and thick ; baldness is exceptional. 

The apoplectic constitution shows itself in persons of small 
stature, with short thick necks, well-developed adipose tissue, 
reddened face, and in dyspnea upon slight exertion. 

The malignant cachexia reveals great emaciation, with a 
peculiar pallor of the face and, usually, -with normal or sub- 
normal temperature. 



THE DECUBITUS, 

The position of the patient in bed shows many things that 
are of use in diagnosis. The normal healthy person usually 
assumes the dorsal position, or lies upon the side. In disease 
there are many changes from this position. In conditions of 
collapse and in many of the acute infectious diseases in which 
great weakness shows itself the patient is inclined to slide 
down to the foot of the bed and sink into a heap. This is 
known as the " passive dorsal " ; associated with this there is 
often stupor and even coma. In many acute diseases of the 
respiratory organs involving one side, such as pleurisy with or 
without effusion, croupous pneumonia, and pneumothorax, the 
patient usually lies upon the affected side. This may be due 
to the fact that breathing upon the affected side is diminished 
in this way as the motion of the side is lessened. In pleurisy 
with effusion there is another advantage in lying upon the 
affected side, as the exudation interferes less by pressure with 
the sound side. In pneumonia patients not infrequently lie 
upon the healthy side, as pain (due to an acute pleurisy) may 
be caused by pressure upon the affected side. In diseases of the 
abdominal organs posture is often characteristic. When there 
is general peritonitis, the patient frequently assumes the dorsal 
decubitus with both legs flexed upon the abdomen. In local 
peritonitis, particularly appendicitis, the right leg only may be 



22 SYMPTOMATOLOGY AND SEMEIOLOGY. 

flexed. In dyspnea and in orthopnea the patient often assumes 
the upright sitting posture in bed or in an easy chair, as this 
attitude favors the accessory muscles of respiration. In disease 
of the brain and spinal cord there is often retraction of the 
muscles of the neck, so that the head seems to sink deeply 
into the pillow. There may be opisthotonos, in which the 
body appears to rest upon the occiput and the heels ; empros- 
thotonos, in which the body appears to bend, forward ; or 
pleurothotonos, in which the body seems bent to one side. 
These positions may be assumed in hysteria. 

THE FACIES. 

A peculiar expression of the face is often found in the dying, 
known as the "fades hippocratica." The facies of abdominal 
disease has also been described, in which the nose, chin, and 
cheeks stand out prominently ; the eyes sink into the orbital 
cavity ; the lips appear red or bluish-red ; the expression is 
weak ; and the entire face shows the appearance of suffering. 
This appearance is also seen in cholera during the stage of 
collapse. The facies, of renal disease is quite characteristic : 
the eyelids are puffy, the face is swollen and edematous, and 
is marked by extreme anemia, showing itself in pallor. 



CONSCIOUSNESS. 

Disturbances of the sensorium are common in diseases 
grouped under the head of internal medicine. They show them- 
selves either in an increased or a diminished psychic activity of 
the brain. Disturbances of the first kind are known as delirium, 
and those of the second variety are known as stupor or coma. 

Delirium. — Delirium must be divided into illusions, in 
which the patient imagines that persons and situations are dif- 
ferent from what he has known them to be in health, in which 
he mistakes one person for another, as in taking his nurse for 
his sister or relative, and so on ; and in hallucinations, in 
which the patient imagines that he sees or hears things which 
in reality have no existence. 

The majority of cases of delirium are due to some toxic 
influence. This may depend upon drugs or upon diseased 
conditions, such as uremia, cholemia, febrile states, and so on. 
Delirium is also very common in disease of the brain and in 
conditions of inanition. The delirium may be either low 



TEMPERATURE. 23 

muttering or active, and develop suicidal or homicidal ten- 
dencies. 

Somnolence. — Sopor, stupor, and coma may be due to nar- 
cotic poisoning. They may occur in toxic conditions, such as 
uremia, diabetes, malignant disease, and conditions that produce 
pressure upon the brain or its membranes. It is also common 
in many of the acute infectious diseases. 



TEMPERATURE, 

The temperature of the body is taken by clinical ther- 
mometers. The bulb of the instrument may be placed in 
the mouth, the axilla, or the rectum. The normal tempera- 
ture of the body in the mouth or axilla is 98. 6° F. ; in the 
rectum it is about a degree higher. In health there is a 
diurnal variation of from a degree to a degree and a half, the 
temperature being lower in the early morning hours (97. 5 F.) 
and higher between five and eight o'clock in the evening 
(99 F.). Any elevation above 99. 5 F. would constitute 
some morbid condition. It should, however, be remembered that 
serious and even fatal diseases may exist with normal or sub- 
normal temperature. 

The following classification of Wunderlich is the one usually 
accepted : 

Range of Temperature. State. Range of Temperature. 

Above 105. 5 F Hyperpyrexia . . . Above 41 ° C. 

Between I03°-I05° F High fever . . . . Between 39.5 °-4.o. 5 ° C. 

Between ioi°-io3° F Moderate fever . . . Between 38. 5°-39.5° C. 

Between 99.5 °-ioi° F Slight fever . . . . Between 38°-38. 5 ° C. 

98.6 , or between 97.5 °~99. 5 F. Normal temperature . . . . 37 C. 

Between 96°-97. 5 F Subnormal temperature . . 37°-36° C. 

Below 96 F Collapse temperature Below 36 C. 

As in health, so in disease, the temperature varies between 
morning and evening. In the early morning there is generally 
a fall, called a remission ; the rise taking place in the evening 
is known as exacerbation. It is customary in febrile cases to 
take temperatures every four, eight, or twelve hours. Occa- 
sionally there is a reverse in this order when the remission 
takes place in the evening and the exacerbation occurs in the 
morning. This is known as the inverse fever type, and 
appears particularly in tuberculosis. 

There are three important types of fever : the continued, the 
remittent, and the intermittent types. The continued type is 



24 SYMPTOMATOLOGY AND SEMEIOLOGY. 

one in which the fluctuations in the twenty-four hours are 
slight, not varying more than one or two degrees. 

It is obvious that as the temperature is not even stable 
during health, it is not so in disease, and a more correct term 
would be the subcontinued type. Such a condition commonly 
occurs in the second week of enteric fever, the temperature 
being subcontinuous. 

By remittent type is meant a fall in temperature, it not 
reaching the normal. This takes place in some forms of 
estivo-autumnal malarial fever, in tuberculosis, in the fever 
from impacted gall-stones, and general septic processes. 

The intermittent type is a type in which the temperature 
falls to normal or below. This occurs in tertian or quartan 
malarial fever, in crisis from croupous pneumonia, and in re- 
lapsing fever. 

The course of the fever is further divided into three stages : 
(i) The onset, period of invasion, or initial stage; (2) the 
fastigium, acme, or height of the fever ; (3) the decline or 
defervescence. 

1. The Period of Invasion. — The period of invasion or 
mode of onset of fever varies greatly. The rise may be rapid, 
with marked chill, or the temperature may rise slowly from 
degree to degree, with preceding symptoms known as pro- 
dromes or forerunners. An example of the rapid onset with 
high temperature occurs in diseases like influenza, croupous 
pneumonia, and malarial diseases. The form in which the 
fever rises gradually is illustrated by enteric fever and, occa- 
sionally, acute rheumatic fever. 

2. The Fastigium. — This varies in different diseases, and 
may not in itself be a serious condition : thus, in diseases like 
typhus fever and croupous pneumonia the fastigium may be 
between 104 F. and 106 F. and remain so for several days, 
or only for a few hours. 

In the malarial fevers the temperature, as a rule, remains 
high but for a few hours, whereas in enteric fever, croupous 
pneumonia, and typhus fever it remains at its height for a week 
or longer. Occasionally, pyrexia may last for several weeks 
or even months. This may take place in diseases like tuber- 
culosis, syphilis, malaria, pernicious anemia, and suppurative 
processes. 

3. The defervescence may be rapid or gradual, favorable or 
unfavorable. When the defervescence is rapid, it is known as 
crisis. When it is gradual or slow, it is known as lysis. In 



TEMPERATURE. 2 5 

crisis there is an abrupt fall in temperature, — three to five de- 
grees or even more, — reaching normal or subnormal ranges, 
accompanied by critical discharges, such as profuse perspira- 
tion, copious diarrhea, or the discharge of a large amount of 
urine. This termination occurs frequently in croupous pneu- 
monia, relapsing fever, and typhus fever. The fall may take 
place in from one to twelve or twenty-four hours. Occa- 
sionally, just before the crisis a rise takes place in the temper- 
ature. This is known as the precritical rise. In lysis the 
temperature falls gradually, taking several days to reach the 
normal. Discharges such as occur in crisis do not take place. 
This mode of termination occurs in enteric fever, broncho- 
pneumonia, acute rheumatic fever, etc. In some diseases 
there may be an abrupt fall of several degrees, the tempera- 
ture, however, not reaching the normal, after which the tem- 
perature rises again. This takes place in -typhus fever and in 
croupous pneumonia, and is known as the pseudo or false crisis. 
It does not always follow that, as a result of crisis, the issue is 
necessarily favorable. The temperature may fall so low that 
collapse takes place, the patient dying in this condition. An 
unfavorable issue may take place from an ascending type, the 
condition being known as hyperpyrexia. In some diseases 
just before death the temperature takes a sudden upward shoot, 
being known as the preagonistic rise. The elevation may 
occur during- the fastiffium, defervescence, or in convales- 
cence. 

Occasionally, complications may arise without showing any 
change in the temperature-curve. Particularly is this true in 
acute rheumatic fever, where endocarditis and pericarditis occur 
without perceptible change in the fever-curve. 

It is rarely possible to diagnosticate a disease from the tem- 
perature alone. Some diseases have what is known as the 
typical temperature-curve, such as the malarial diseases, 
enteric fever, typhus fever, relapsing fever, and croupous pneu- 
monia, but modifications in the curve are very apt to take 
place, and all symptoms and signs must be taken into account 
before the diagnosis is reached. 

The temperature in convalescence from fever is much more 
unstable than the normal, modifications in the curve being due 
to slight causes : thus, changes in diet, visits of friends, or 
constipation may send the temperature upward, this condition 
being known as a recrudescence. The temperature-curve is 
further influenced by the age of the patient, previous condition 



26 SYMPTOMATOLOGY AND SEMEIOLOGY. 

of health, by idiosyncrasies, and by the presence of complica- 
tions. In childhood the temperature is more easily disturbed 
than in adults, is more apt to run an erratic course, and is less 
subject to the ordinary laws of pyrexia. Slight ailments in 
children, as intestinal catarrh, may send the temperature to 
103 ° F. or 105 F. Teething and prolonged spells of crying 
may have the same effect. In serious affections the temperature 
in childhood is liable to rise more abruptly and attain a higher 
range than in adults, whereas the duration is apt to be briefer. 
In the extremes of age, in infants and in old persons, the oppo- 
site is likely to occur. Thus, a severe illness which is ordi- 
narily characterized by high temperature may occur with only 
a subfebrile fever-curve. 

Alcoholics rarely show high temperature. Young adults in 
previous good health commonly show high temperature. As 
a rule, the temperature rises with the complication. An abrupt 
or considerable fall, if not due to crisis, is also significant of 
complications, especially internal hemorrhage. Occasionally, 
the hectic curve may occur after the crisis of croupous pneu- 
monia. If persistent elevation of temperature takes place after 
convalescence has been reached, the condition is known as a 
relapse, in contradistinction to the recrudescence, in which the 
rise is only temporary. 

Subnormal Temperatures. — A subnormal temperature oc- 
curs in quite a number of recognized morbid conditions. It 
takes place in diabetes, myxedema, chronic cardiac, renal, and 
hepatic diseases, and in many forms of mental diseases (insanity). 
The condition is also common in internal malignant growths. 

When the temperature falls below 96 F., the condition is 
known as collapse. As has already been indicated, it may 
take place from crisis, from hemorrhage or perforation of the 
intestines, from apoplexy, cholera, or from fracture or disloca- 
tion of the spine with injury to the cord. 

EXAMINATION OF THE SKIN. 

A large number of diseases of internal organs are associated 
with some alteration in the appearance of the skin. This may 
be so characteristic that the diagnosis can be made alone from 
the examination of the skin. In diagnosis the following points 
must be taken into consideration : changes in color ; eruptions 
(exanthemata) ; changes in reference to dryness or moisture 
of the skin ; edema and emphysema. 



EXAMINATION OF THE SKIN. 2J 

The State of the Nutrition of the Skin. — In very old age 
the skin of the entire body seems to be thinner, in which 
probably the subcutaneous cellular tissues share in the atrophy. 
In earlier years this condition only takes place in forms of 
severe cachexia, in which the skin is dry and thin, with loss of 
tone, and when lifted in a fold, resumes its place very gradually. 
Many forms of atrophy of the skin have been described, but 
they belong to the domain of dermatology. 

The color of the skin of a healthy person shows many 
variations, due to age, occupation, climate, and race. In some 
nations the pale, in others the more florid or red, complexion 
predominates. Any one is able to appreciate at a glance what 
the healthy appearance of the skin under normal conditions 
should be. 

In disease attention must be given particularly to the fol- 
lowing changes : (i) The pale skin ; (2) the red skin ; (3) the 
cyanotic or blue-red skin ; (4) the icteroid or jaundice skin 
(yellow) ; (5) the bronze skin ; (6) the gray skin. 

I. The Pale Skin. — This may occur in physiologic condi- 
tions, especially in persons who are confined to indoor occupa- 
tions and do not often come in contact with the open air. The 
condition is often present in disease. The pallor of the skin is 
noticed particularly upon those parts of the body that, under 
normal circumstances, due to the thinness of the skin and 
great degree of vascularity, are apt to show a red color, 
especially upon the cheeks, lips, lobule of the ear, and the 
under surface of the eyelids. The various shades of pale skin 
are divided into the alabaster color, yellowish, waxy, yellow- 
green, and lemon-yellow. The nutrition of the body bears 
no necessary relation to the pallor of the skin, as frequently 
persons are found with well-developed muscles and adipose 
tissue, characterized by extreme pallor. Duration of the pallor 
and particularly its cause show an influence upon the state of 
nutrition. Pallor of the skin under all circumstances depends 
upon the quantity and quality of the blood that circulates in 
the vessels. There may be abnormal paleness if there be 
either too little or impoverished blood circulating in the capil- 
laries of the skin. The cause of the paleness may therefore 
be due to the decrease in the motor power of the heart or in 
the blood-vessels, or to a deficiency in the amount of hemo- 
globin. The diagnosis between these two conditions can, how- 
ever, only be made with certainty by an examination of the 
blood. Primary pallor may be due to syncope or fainting, to 



25 SYMPTOMATOLOGY AND SEMEIOLOGY. 

emotion , fright, to cold, as in the chill of fever, in spasm of 
the capillary vessels, and in allied conditions. 

Paleness is encountered in persons suffering from fatty de- 
generation of the heart. This may be due to the diminished 
amount of force of the heart muscle, in which condition the 
vessels of the skin are not properly filled. Pallor furthermore 
takes place after hemorrhages, whether they be large or small 
and frequently repeated. It occurs in bleeding from the nose 
(epistaxis), bleeding from the gums, spitting of blood (liemop- 
tysis), vomiting of blood {liematemesis), blood from the in- 
testines (enter orrliagla), blood in the urine (hematuria). The 
condition is also found in internal hemorrhages, such as bleed- 
ing into a pulmonary cavity, pleura, and pericardium, from 
malignant disease, tubercle, or scurvy. It may occur from 
parasites, especially those appearing in the bowel, such as the 
anchylostoma duodenale. Pallor of the skin due to blood loss 
may be also, although indirectly, associated with disease of the 
kidney, purulent exudation in the pleura, pericardial or peri- 
toneal sacs, or due to accumulation of pus in other localities. 
Persons with chronic disease of the gastro-intestinal tract in 
which digestion is interfered with are apt to suffer from pallor. 
Ulcer of the stomach and chronic catarrh of the stomach 
and bowel will cause pallor. It is likely to affect persons suf- 
fering from intestinal parasites, particularly the various vari- 
eties of tapeworm. There is pallor in diseases of the blood. 
It is a symptom of chlorosis, leukemia, pseudoleukemia 
(Hodgkin's disease), and pernicious anemia. Pallor of the 
skin is further found in association with acute and chronic in- 
fectious diseases, such as malaria, acute rheumatic fever, diph- 
theria, tuberculosis, and malignant disease. Lastly, it may be 
due to metallic poisoning, particularly lead, mercury, and 
arsenic. 

2. The Red Skin. — The red appearance of the skin may 
also be noticed best upon the lips, cheeks, mucous membrane 
of the conjunctiva, and the lobule of the ear. Persons who 
expose the face to the open air are likely to have a red skin. 
It is noticed especially in those who labor in the sun. It may 
be temporary, appearing and disappearing rapidly. This may 
occur in nervous, excitable persons, or under slight psychic 
impressions, as in blushing. Persons who are continually ex- 
posed to heat often have red skin, especially cooks, smiths, and 
so on. The red skin is common after warm bathing. It may 
depend upon the active dilatation of the vessels of the skin, or 



EXAMINATION OF THE SKIN. 29 

to an increase in the total mass of the blood in the vessels of 
the skin, or to an increased amount in the corpuscles and color- 
ing-matter of the blood. Abnormal redness of the skin may 
occur in hemicrania. It is present most frequently in fevers. 
It is often noted in plethoric conditions, in individuals called 
full-blooded, and in poisoning from drugs such as atropin. 

3. The Blue-red or Cyanotic Skin. — This shows itself most 
prominently upon the parts that are normally bright red, such 
as the lips, cheeks, mucous membranes, and the finger-nails. 
If the condition is marked, it may show itself all over the sur- 
face of the body. Occasionally, cyanotic areas are combined 
with pale skin, when the condition is spoken of as livid. 
Cyanosis is due to the accumulation of carbonic acid in the 
blood and a deficient amount of oxygen, the blood having a 
venous or hypervenous character. It may arise from an in- 
terference of the change of gases in the lungs, preventing the 
blood from accumulating sufficient oxygen and not allowing 
itself to lose sufficient C0 2 ; or it may be due to a diminution 
in rapidity of the circulation of the blood in the capillaries, so 
that it gives off more oxygen and absorbs less C0 2 , hence 
the condition arises particularly in disturbances of the respira- 
tion or circulation. Should both conditions be coexistent, a 
high grade of cyanosis will develop. 

Diseases of the Respiratory Organs Causing Cyanosis. — 
The condition may be caused by a narrowing of the large air- 
passages, so that the atmospheric air can only partly gain 
access to the alveolar structure of the lungs. Acute and 
chronic inflammations of the pharynx or larynx, retropharyn- 
geal abscesses, or diphtheria may lessen the lumen of the 
trachea and produce cyanosis. It may also result from croup- 
ous bronchitis, bronchial asthma, paralysis of the vocal cords, 
especially of the dilator of the glottis (crico-arytenoideus pos- 
terior), emphysema, and disease of the alveolar tissue of the 
lungs, or of the parenchyma of the lungs, or a combination 
of these conditions. It may occur from the presence in the air- 
passages of foreign bodies, tumors, goiters, aneurysms, or from 
enlarged glands. It is caused by all forms of consolidation. 
Tuberculosis may produce a high grade of cyanosis. Compres- 
sion of the lung from pleural and pericardial effusion or accu- 
mulation of gases in the serous sacs may produce extreme cyan- 
osis. It rarely results from pressure upward from the abdominal 
organs, such as meteorism, tumors, and large accumulation 
of fluid in the peritoneal sac. It may result from paralysis of 



30 SYMPTOMATOLOGY AND SEMEIOLOGY. 

the respiratory muscles, bulbar paralysis, peripheral neuritis, 
paralysis of the diaphragm, spasm of the respiratory muscles, 
epilepsy, trichinosis, occasionally from hysteria, and from va- 
rious diseases of the muscular tissues themselves, such as the 
myopathic form of progressive muscular atrophy and myositis 
ossificans. 

Cyanosis due to disease of the circulatory apparatus 
may be due to lesions of the heart itself or of the per- 
ipheral vessels. Contraction of the smaller vessels at the 
periphery, in slowing the circulation, may produce cyanosis, 
as from the influence of cold. Peripheral cyanosis may be due 
to the interference of the return of the blood supply, as in pre- 
paring a part for bleeding. The same condition takes place 
in thrombosis of the veins or from compression of tumors 
upon a part. Causes due to the heart itself may be found in 
disease of the valves of the heart, in failure of compensation 
from valvular disease, cyanosis often developing to a high de- 
gree. Cyanosis is pronounced in stenosis of the pulmonary 
valve, and is a prominent symptom in congenital valvular dis- 
ease. Disease of the heart muscle itself, whether it be due 
to disturbance of innervation, inflammatory or degenerative 
processes of the muscle substance itself, produces cyanosis, as 
this diminishes the force and activity of the circulatory appa- 
ratus. A similar result may occur from effusions or accumu- 
lation of gas in the pericardium. Cyanosis of a high grade is 
often encountered from the toxic effects of drugs, such as nitro- 
benzol, from the coal-tar products, such as antifebrin, antipyrin, 
phenacetin, kairin, thallin, and others. It may occur from the 
inhalation of illuminating gas. The cyanosis in such instances 
is due to the fact that the blood loses its power of absorbing 
sufficient oxygen. 

4. The Icteroid or Jaundice Skin. — The icteroid skin 
develops when bile or bile pigments circulate in the blood 
stream. The condition is easily recognizable. In mild grades 
there is a light sulphur-yellow appearance of the skin. This 
is always most pronounced in the conjunctiva. It can 
easily be discovered, if present to a slight degree, by tak- 
ing a glass slide and pressing it upon the mucous mem- 
branes of the tongue, when the yellowish color will be 
noticed. If the condition is more intense, the lemon-yellow 
will develop into a tinge of darker yellow — even to a brown- 
ish-yellow color known as melasicterus. Jaundice can not 
be detected by artificial light, since yellow artificial light does 



EXAMINATION OF THE SKIN. 3 1 

not enable one to distinguish between white and yellow. In 
mild cases it is best detected in the conjunctiva. Occasion- 
ally, in the negro the conjunctiva shows a yellowish cast. This 
does not necessarily indicate jaundice. As jaundice begins 
to develop it does not show itself in all parts of the skin with 
equal intensity : the yellowish appearance is most pronounced 
in parts in which the epidermis is thin, such as the angles of 
the mouth and the alae of the nose, the forehead, and the skin 
of the neck, the chest, abdomen, and extremities being the last 
parts to be affected. Jaundice is usually more intense at the 
flexures of the joints. At the commencement of the icteroid 
appearance the yellow color is particularly due to the blood 
plasma that has accumulated bile pigment and so produced the 
abnormal color ; later, the cells of the rete Malpighii absorb 
bile pigment and retain it for some time. This explains the 
slow disappearance of jaundice and the return to normal color 
in many diseases in which jaundice has persisted for any length 
of time. Jaundice is divided into hepatogenous and hemo- 
hepatogenous jaundice. 

Hepatogenous Jaundice. — Hepatogenous jaundice is the 
jaundice of stagnation, being the result of an interference with 
the flow of bile from the liver or the bile-ducts to the common 
bile-duct into the intestine. This produces stasis. The bile be- 
comes thin, being absorbed into the blood. This results from 
catarrh of the bowel, especially the duodenum, affecting the com- 
mon bile-duct, tumors pressing upon the duodenal opening of the 
common duct, cancer of the head of the pancreas, parasites in 
the common bile-duct, and gall-stones lodging there. The 
hepatic duct may also be compressed by tumors or cysts {can- 
cer, echinococcus), or obstruction in the small bile-ducts of the 
liver. Compression of branches of veins of the liver or catarrh 
of the small bile-duct possibly produces jaundice. The symp- 
toms produced by jaundice are, first, the yellow skin, particularly 
in the parts that have just been enumerated ; the appearance 
of bile pigment in the urine ; clay-colored stools ; slowing of 
the pulse ; headache, and other nervous manifestations. There 
may sometimes be subnormal temperature, and, if the condition 
continues, stupor and coma with convulsions may develop. 
Such a condition is known as cholcmia. 

Hemohepatogenous Jaundice. — For some time it has been 
well established that jaundice occurs in certain forms of poison- 
ing and in the infectious diseases. In such instances the icterus 
is due to the marked alteration in the blood, and is character- 



32 SYMPTOMATOLOGY AND SEMEIOLOGY. 

ized chiefly by an alteration in the erythrocytes and in the 
hemoglobin. This form of jaundice takes place in poisoning 
by chloroform, phosphorus, ether, chloral, potassium chlorate, 
and arsenic. In the infectious diseases it is most noticeable in 
yellow fever, pyemia, and, occasionally, in croupous pneumonia. 
In either instance, however, it must be remembered that the 
liver itself may bear some share in the production of the icte- 
roid condition. In the hemohepatogenous variety the urine 
does not, as a rule, show bile pigments, nor are the feces likely 
to be clay colored. Only in grave alterations of the hemo- 
globin and corpuscles does hemohepatogenous jaundice show 
itself. 

Icterus Neonatorum. — This is the jaundice of the new- 
born, and may be either benign or malignant. The explana- 
tion of the condition is very doubtful. It has been attributed 
to purely mechanical conditions, such as the sudden decrease 
of pressure in the portal veins, also alterations in the blood 
itself. Neither of these explanations is satisfactory. 

5. The Bronze Skin. — In 1855 Addison called attention 
to the peculiar bronze-like discoloration of the skin that was 
almost constantly associated with the chronic diseases of the 
suprarenal capsules. The bronze skin shows itself by a brown - 
grayish to black discoloration, especially upon the exposed 
parts of the body, such as the face and hands. From these 
parts it may gradually extend all over the body, excepting the 
nails and cornea, which usually remain clear. The mucous 
membranes are similarly affected, the lips, however, showing 
the discoloration less. It is due to the deposit of pigment in 
the rete Malpighii. Pressure with the finger does not cause the 
discoloration to disappear. The administration for a long time 
of some drugs, particularly arsenic, may cause a similar dis- 
coloration of the skin and mucous membranes, which does not 
always disappear even after the arsenic has been discontinued. 

6. The Gray Skin. — After the salts of silver have been 
administered for some time, fine particles begin to deposit in 
the skin, sweat-glands, and even in some of the internal organs, 
as in the kidneys or intestines. The color may be grayish or 
blackish, and especially affects the face and hands. In well- 
marked cases the mucous membrane of the mouth may also 
show discoloration. This condition is known as argyria. 



ERUPTIONS. 33 



ERUPTIONS (EXANTHEMATA). 

There are certain eruptions that have a general diagnostic 
value, such as herpes, roseola, and sudamina (miliaria). 

Sudamina occur in all diseases in which sweating is a prom- 
inent symptom. They show themselves by a slight elevation of 
clear fluid under the skin, being about the size of an ordinary 
pinhead. The place at which this eruption most commonly 
appears is upon the lower part of the abdomen. It occasion- 
ally occurs in health, owing to too prolonged bodily exertion 
or as a consequence of exposure to the direct rays of the sun. 
They appear commonly during the course of many acute infec- 
tious diseases. They are also found in chronic pulmonary tuber- 
culosis, in miliary tuberculosis, in acute rheumatic fever, in 
enteric fever, especially toward the end of the third week, and 
in pyemia. Sudamina may also often show themselves in the 
stage of sweating that takes place just prior to death. 

Herpes also show themselves by the development of small 
vesicles. These are most often larger than those of sudamina, 
and they occur in groups. They are occasionally confluent. 
The vesicles at first contain clear fluid, which later may become 
cloudy and occasionally yellowish, for pus-formation takes 
place. They soon desiccate, leaving a crust that does not 
form a cicatrix upon the skin. The most common site for 
the appearance of the herpes is in the neighborhood of the 
mouth, especially upon the lips, when the condition is known 
as herpes labialis ; or it may appear at the nose, when it is 
known as herpes nasalis ; or near the eyelids, when the con- 
dition is known as herpes palpebralis. The diseases most com- 
monly found associated with herpes are croupous pneumonia, 
cerebrospinal fever, malaria, relapsing fever, and erysipelas. 
The eruption is occasionally noted in gastro-intestinal catarrh. 
It sometimes appears during the course of menstruation, and 
may depend upon nervous influences, such as fright, anxiety, 
etc. The eruption is exceedingly rare in enteric fever and in 
typhus fever, and is said never to occur in tubercular meningitis. 

The roseolar eruptions are of especial value in some of the 
most important diseases. They show themselves by round, 
rose-red, slightly raised points (maculopapular) that disappear 
upon pressure. They are usually found scattered upon the 
lower part of the abdomen, the chest, the back, particularly 
between the shoulder-blades, and rarely upon the extremities 
and the face. They are from two to three lines in diameter. 
3 



34 SYMPTOMATOLOGY AND SEMEIOLOGY. 

The eruption very closely resembles flea-bites. This is the 
characteristic (specific) eruption of enteric fever. It occurs 
about the end of the first or the beginning of the second week. 
The individual eruption lasts from two to three days, and 
appears and disappears in successive crops. The eruption of 
measles may occasionally resemble this, but in morbilli the 
eruption is coarser, more raised, does not disappear upon pres- 
sure, and is found prominently upon the face. Eruptions may 
appear from the use of certain drugs or poisons, and may show 
themselves in various forms. They may occasionally resemble 
the acute exanthematous diseases, such as scarlet fever and 
measles, and may give rise to difficulty in diagnosis. The drugs 
that are most likely to cause eruptions are quinin, antipyrin, 
salicylic acid, morphin, atropin, strychnin, various balsams, par- 
ticularly copaiba, iodin, bromin, and substances that are applied 
locally, such as turpentine and mustard. 

When hemorrhages occur under the skin, the condition is 
known as purpura. When it occurs in small spots, they are 
known as petechia. When the eruption appears in large 
patches, it is known as ecchymosis. 

Cicatrices. — Cicatrices upon the skin are often of import- 
ance. The eruption of smallpox, especially upon the exposed 
parts, — the face and the hands, — leaves a well-marked cicatrix. 
Many of the syphilitic eruptions leave prominent cicatrices. 
The strise, or the scars of pregnancy, show themselves upon 
the lower part of the abdomen and upon the thigh. Similar 
scars sometimes occur after marked edema of the abdomen. 
The scars from injuries have no importance in clinical medicine. 



EDEMA. 

This has already been partially described in a previous sec- 
tion ; further reference must, however, be made at this point. 
By edema is meant an abnormal accumulation of fluid in the 
tissues : accumulation particularly in the cellular meshes and 
lymphatic spaces, being a transudate from the blood-vessels. 
The fluid may be absorbed by the lymphatics, and again find 
entrance into the blood. The condition is recognized by an 
increase in volume in the affected part and the swelling filling 
up depressions and cavities, the skin appearing puffy and pitting 
upon pressure. The skin is usually slightly shining and smooth, 
often accompanied by pallor, due to the diminished circula- 
tion. (See p. 20.) 



EMPHYSEMA OF THE SKIN. 35 

EMPHYSEMA OF THE SKIN, 

By this is meant entrance of air into the cellular tissues, 
and, depending upon its distribution, it may be spoken of as 
circumscribed or local and general or diffused. The recogni- 
tion of the condition is not difficult. The affected parts are 
raised, and upon palpation give a peculiar crepitant sensation 
to the finger similar to that which is encountered when normal 
lung tissue is felt. Upon pressure with the finger a slight 
temporary depression may occur, and the condition may re- 
semble edema, but the resemblance is only slight, for in edema 
the sensation of crepitation is entirely absent. Emphysema 
may show itself in two forms : first, the so-called spontaneous 
emphysema of the skin, which may depend upon inflammations 
or abscesses or large extravasations of blood without having 
communication with the external air, in which gas is developed 
in the subcutaneous tissues. It may be due to the gas-pro- 
ducing bacilli (bacillus aerogenes capsulatus), and belongs to 
the domain of surgery. The second form is known as aspira- 
tion emphysema,, and may be due to the entrance of air from 
an external wound, such as from tracheotomy. Many of these 
causes also belong to the domain of surgery, internal medicine 
concerning itself only with those cases in which air enters from 
diseases of internal organs. Such conditions may arise from 
ulcerative processes of the trachea and bronchi, in which per- 
foration may take place, in disease of the pulmonary structure, 
such as cavities in the lungs, which may ulcerate into the chest- 
wall and develop a communication with the subcutaneous tissue. 
Pulmonary alveoli may rupture from great intrathoracic pres- 
sure, such as severe cough. This may take place particularly 
in children with whooping-cough, bronchitis, or emphysema, 
from sharp crying, severe exertion, such as blowing upon 
wind-instruments, glass-blowing, etc. Air may enter from 
under the pleura into the interalveolar tissue, reach the medi- 
astinum, and thus get into the subcutaneous tissues of the 
neck and spread onward ; finally, emphysema of the skin may 
occur from disease of the esophagus, stomach, or intestines. 
This may result from rupture, from ulceration, malignant dis- 
ease, or foreign bodies. It is a prominent occurrence in perfor- 
ation of the bowel or stomach in which the abdomen soon be- 
comes filled with gas, and is a symptom of peritonitis due to 
perforation. 



36 SYMPTOMATOLOGY AND SEMEIOLOGY. 

MOISTURE OF THE SKIN. 

In health the secretion of sweat is variable, and this condi- 
tion is apt to be exaggerated in disease. When sweating occurs 
to a high degree, the condition is known as hyperhidrosis. 
When sweating is much diminished, it is called hyphidrosis ; 
and when sweating is arrested altogether, the skin being per- 
fectly dry, it has received the name of anidrosis. Marked 
sweating over the whole surface of the body is called hyper- 
hidrosis universalis ; if it be confined to a part, hyperhidrosis 
localis is spoken of. If it appear only upon one side of the 
body, it is spoken of as hemidrosis. Many influences may 
bring about these conditions, such as changes in the blood 
and lymph. The accumulation of urinary products, of carbonic 
acid, the auto-infections, bacteria, chemic bodies, and poisons 
may suppress or produce perspiration. They may act either 
upon the sweat-glands themselves or directly upon the nervous 
system. Sweating occurs during convulsions due to the in- 
creased amount of muscular work and increased activity of the 
heart. On the other hand, it may be entirely absent in epilep- 
tics and in hysteria. It results from great excitement, fright, 
severe pain, after warm bathing, occasionally from the influence 
of atmospheric heat, and from certain drugs, as sudorifics 
(pilocarpin). Dyspnea may be accompanied by sweating. 
Sweating occurs in many of the febrile diseases, especially in 
diseases ending by crisis, such as croupous pneumonia, relaps- 
ing fever, or malaria. It takes place in other febrile conditions 
that are marked by fall of temperature, such as pyemia, the 
night-sweats of phthisis, the latter stages of enteric fever, and 
in the cold sweats of collapse. Acid sweats are met with 
particularly in acute rheumatic fever. Local sweating is often 
a prominent symptom in organic disease of the nervous system. 
It occurs in migraine, localized disease of the brain, pressure 
upon the sympathetic nerve, and is often a symptom in ex- 
ophthalmic goiter and in many mental diseases. Diminished 
sweating or complete anidrosis occurs in diseases characterized 
by continued high temperature. It may be due to the loss of 
considerable amounts of fluid from the tissues, as in diseases 
of the bowel, as severe diarrhea, or to contracted kidney and 
diabetes. 



THE PULSE. 37 

THE PULSE. 

From contraction of the ventricles, a certain amount of blood 
is sent into the aorta and thence into the peripheral arteries. 
In this way the lumina of the arteries are widened, which shows 
itself in two directions — in an increase of their transverse 
diameters and in an extension of their long diameters. This 
gives rise to pulsations that correspond very closely to the 
systolic or first sound of the heart. For purposes of exami- 
nation the right pulse is chosen, on account of its convenience. 
The pulse depends principally upon three conditions : the 
amount of work done by the heart, the quantity of blood in 
the artery, and the condition of the arterial wall itself. In a 
great many diseases the pulse is of importance in diagnosis. 
For purposes of examination palpation of the pulse or feeling 
of the pulse (sphygmopalpation) is all that is ordinarily re- 
quired. For purposes of exact examination an instrument is 
used, by which means pulse-tracings are obtained. This in- 
strument is called a sphygmograph, and the tracing is called 
the sphygmogram. An instrument has been invented for 
measuring the pressure of the pulse, known as a sphygmoma- 
nometer. 

Palpation of the Pulse. — Sphygmopalpation. — For pur- 
poses of examining the pulse the second or third finger of the 
right hand should be placed upon the radial artery, at or near 
the styloradial process. Firm pressure should be avoided, as 
this may produce changes in the rhythm and frequency. Three 
things must be noticed in examining the pulse : its frequency, 
its rhythm, and its quality. 

Pulse Frequency. — In the ordinary healthy adult the pulse 
varies between sixty and eighty beats a minute : seventy may 
be taken as the average pulse. For purposes of convenience 
the pulse is counted with the second-hand of the watch, and 
for exact study an entire minute should be counted. Beginners 
should not content themselves with counting for fifteen seconds, 
as many circumstances may produce errors. Frequently, when 
the pulse is first felt it is apt to be slightly more rapid than 
it would be at the latter part of the minute, on account of 
excitement due to the examination. The pulse frequency 
normally depends upon the age and position of the patient, 
the taking of food, excitement, exercise, respiration, the tem- 
perature of the air, and the influences of certain poisons. In 
the first few weeks following birth the pulse is highest, and it 



38 SYMPTOMATOLOGY AND SEMEIOLOGY. 

gradually diminishes up to the twenty-fifth year of life. It 
remains at its minimum between the ages* of twenty-five and 
fifty, and increases again as old age is reached. During fetal 
life the pulse is from 135 to 140 a minute. During the first year 
of life it averages about 134 a minute ; from the first to the 
second year, about 1 10 a minute ; from the fifth to the sixth 
year, about 98 a minute ; from the tenth to the eleventh year, 
about 88 a minute; from the fifteenth to the twentieth year,. 
72 a minute ; from the twenty-fifth to the fiftieth year, 70 a 
minute ; from the sixtieth to the eightieth year, between 74 
and 79 a minute. These are the observations of Eichhorst. 
The influences of sex depend upon the fact that the pulse is 
more frequent in females than in males. This pulse frequency 
even exists during fetal life, and led Frankhauser to attempt 
to foretell sex in the fact that the pulse of the female is from 
five to ten beats a minute more frequent than that of males. 
This difference is less marked between the ages of twenty-five 
and thirty, when the pulses are more uniform. Position of 
the person is of importance. It shows its influence in the 
fact that the pulse is slowest in the recumbent posture, and 
most frequent in the erect posture. The time of day is also 
not without importance. The pulse-beats are more frequent 
in the early morning hours, between three and six o'clock, 
and the pulse reaches its maximum about eleven o'clock in 
the morning ; the frequency then declines until about two 
o'clock in the afternoon, when it begins to rise, and continues 
until between six and eight o'clock in the evening, when it 
reaches its second maximum ; it then begins to decline in fre- 
quency until midnight. , 

The taking of food has a decided influence upon the pulse 
frequency. Thus, after meals, especially if hot, indigestible 
food and liquors are partaken of, there is a marked increase in 
the frequency of the pulse. Abstinence from food or fasting 
decidedly diminishes the pulse-rate. Exercise increases the 
pulse-rate. Deep respiration has a similar effect. The tem- 
perature of the air has an influence ; thus, a high temperature 
increases the frequency of the pulse, and low temperature 
slows the pulse. Atmospheric pressure, as in a pneumatic 
cabinet, decreases the pulse-rate. Rarefied air, as in mountain 
regions, on the contrary, increases the pulse-rate. Influences 
upon the pneumogastric nerve produce variations in the pulse ; 
thus, irritation decreases, whereas division or paralysis of the 
nerves increases, the pulse-rate. Drugs have an important in- 



THE PULSE. 39 

fluence ; thus, digitalis and calabar bean diminish the rapidity 
of the pulse ; veratrum and nicotin in small doses slow the 
pulse ; in larger doses they increase the pulse. Atropin 
increases the pulse-rate. 

Morbid conditions show their influence upon the frequency 
of the pulse in two ways : they may slow the pulse {pulsus 
rarus) or they may increase the pulse-rate {pulsus frequens}. 
Slowing of the pulse is present in the following conditions : in 
jaundice the pulse-rate is frequently, although not invariably, 
diminished. It may fall to fifty or forty or even lower a 
minute. It has lately been proved by Legg and others that 
bile pigment absorbed in the blood has an influence upon the 
heart muscle and ganglia, and in this way a slowing pulse- 
rate is produced. Degeneration of the heart muscle produces 
a slowing of the pulse. Stokes called attention to the fact 
that in fatty heart and in arteriosclerosis of the coronary arte- 
ries, also in myocardiac affections, the pulse frequency is de- 
creased. A case has been recorded in which, from this cause, 
the pulse-rate fell to eight a minute. In stenosis of the aortic 
valves Traube has shown that in the majority of cases the 
pulse-rate is slowed as the coronary arteries and the heart 
muscle do not receive sufficient blood. In disease of the cen- 
tral nervous system the pulse is often slowed in a remarkable 
degree. From increased pressure upon the cerebral substance 
from growths, from hemorrhage, from hydrocephalic fluid in the 
course of basilar meningitis, or from inflammation of other 
parts of the vagus (pneumogastric nerve) the pulse frequency is 
often markedly diminished. In suddenly lowered blood pres- 
sure in the arterial stream from large hemorrhages or from 
bleeding, as a therapeutic measure, the pulse frequency is de- 
creased. The same effect may be observed after aspiration of a 
pleural or pericardial effusion. In the crisis from acute infec- 
tious diseases the pulse-rate is frequently diminished. In con- 
ditions of inanition either due to want of food or stenosis of the 
esophagus, or in chronic catarrh of the stomach and bowel, 
the pulse-rate may be lessened. Occasionally, it occurs in 
the course of acute rheumatic fever without intercurrent car- 
diac affection and in parturition ; this Olshausen attributes to 
lipemia. In some of the intoxications — thus, from lead or 
alcohol — the pulse-rate may be decreased. 

Increase in the Pulse-rate (Pulsus Frequens). — Increase in 
the pulse-rate occurs under the following pathologic circum- 
stances : In fever it is one of the most constant symptoms ; in 



40 SYMPTOMATOLOGY AND SEMEIOLOGY. 

this condition one should always suspect complications if, 
during the course of fever, the pulse-.rate should diminish in 
frequency. In the majority of cases the pulse frequency at 
the height of the fever shows a certain proportion. Accord- 
ing to Liebermeister the pulse-rate rises to eight beats a 
minute for each degree in the rise of the fever ; however, 
many exceptions occur to this rule, and many factors may 
influence the condition. The prognosis in all febrile diseases 
should be considered extremely serious if the pulse-rate 
should rise to 160 a minute or over. When febrile diseases 
occur in weak or cachectic individuals, the proportion between 
pulse and fever is apt to be higher ; thus, in febrile conditions 
in such individuals the pulse is apt to be very much higher 
than the temperature would indicate. The same is true in 
febrile diseases occurring in infancy, and in febrile diseases 
taking place in persons affected with valvular disease of the 
heart. In enteric fever and in yellow fever a lower pulse- 
rate is usually encountered than in other febrile diseases. In 
acute miliary tuberculosis, septicemia, and pyemia, the pulse- 
rate is very high. 

In collapse if the temperature should fall to 96° F. or 
below, the pulse-rate is very apt to be greatly increased in 
frequency. The prognosis in such conditions is always serious. 
The pulse-rate may become extremely rapid, amounting to 
200 a minute or more. In such cases it is almost impossible 
to count the pulse-rate with accuracy. It should be done by 
counting the contraction of the ventricles by auscultating the 
heart, or every other pulse-beat may be counted and the 
number doubled a minute. In paralysis of the pneumogastric 
nerve, which may be due to disease of the central nerves at 
the origin of the vagus or any part of its course, the pulse- 
rate is markedly increased. Paralysis of the pneumogastric 
occurs most frequently from pressure from enlarged lymphatic 
glands, such as might result during the course of pseudo- 
leukemia (Hodgkin's disease). In certain neuroses of the 
heart muscle, such as nervous palpitation, stenocardia, and 
exophthalmic goiter (Graves' disease), a marked increase in 
the pulse-rate may take place. In many valvular diseases of the 
heart, especially during the stage of ruptured compensation; 
in cases in which there is great difficulty in the flow of the 
blood through the arterial system, such as from the accumu- 
lation of pleuritic exudation and also from the accumulation 
of fluid in the pleural sac pressing upon the large vessels, the 



THE PULSE. 41 

pulse frequency is apt to be increased. In diseases of the 
lungs in which there is difficulty of the blood emptying itself 
from the pulmonary artery the pulse-rate is more rapid. 
Pain markedly increases the rapidity of the pulse. In dis- 
eases of the blood, such as chlorosis and pernicious anemia, 
the pulse-rate is often increased. A very slow pulse — under 
60 a minute — is known as bradycardia. A pulse-rate of 1 20 
or over is known as tachycardia. 

Rhythm of the Pulse. — Three varieties of rhythm of the 
pulse have been described : the rhythmic, the allorrhythmic, 
and the arhythmic (irregular) pulse. In normal healthy indi- 
viduals the pulse shows regular rhythmic intermission. This 
is known as the rhythmic pulse. An experienced finger can 
readily detect this condition, and can easily detect alterations in 
the normal pulse. A double pulse-beat is known as dicrotism. 
This condition takes place in fevers (enteric fever), convales- 
cence, and anemic conditions. Frequently there is a decided 
pause between the first strong beat and the second weaker 
beat ; occasionally it may happen that there may be more than 
one beat following the first. In rarer instances the first beat 
may be the weaker one, and the second beat the more pow- 
erful. The latter condition has been called the hyperdicrotic 
pulse. The term allorrhythmia was introduced by Sommer- 
brodt. By this term it is understood that although the pulse 
does not conform to the normal rhythm, it nevertheless shows 
a decided periodicity of rhythm. To this variety belong the 
pulsus paradoxus , pidsus bigeminus, and the pulsus altemans. 
Allorrhythmia must be very pronounced to be appreciated by 
the finger, and experienced and practised observers may err 
unless sphygmographic tracings are taken of such pulses. The 
pulsus paradoxus is one that becomes smaller and may even 
entirely disappear during inspiration. The pulsus bigeminus 
has for its characteristic that it is made up of two beats, one 
following the other, succeeded by a somewhat prolonged 
pause. The pidsus altemans shows a regular changeability 
between a large and a small pulse. By the arhythmic pulse is 
meant one that shows decided irregularity in reference to the 
succession of beats. It has sometimes been called the pidsus 
intermittens. 

Quality of the Pulse. — Three things must be noted in ref- 
erence to the quality of the pulse : expansion, strengtli, and size. 
In reference to the expansion, a rapid pulse {pulsus celer) and 
a slow expansion pulse {pulsus tardus) may be recognized. 



42 SYMPTOMATOLOGY AND SEMEIOLOGY. 

The pulsus celer shows itself in the fact that the artery reaches 
its maximum of expansion in a very short period of time. 
This is apparent to the finger by the fact that the beat rapidly 
disappears. In the pulsus tardus the opposite condition is 
noted. Both these pulses occur commonly in diseases of the 
aortic valves, aortic insufficiency exhibiting the pulsus celer, 
and stenosis of the aortic valves showing the pulsus tardus. 
In very many cases the pulsus celer is also the frequent (rapid) 
pulse. ■ An important variety of the pulsus celer, as has 
already been indicated, occurs in aortic regurgitation. It is 
known as the trip-hammer \ water-hammer, receding, or Corrigan 
pulse. The pulse is more characteristic when the ventricular 
contractions are short, and the less the flow of the blood 
is hindered from the small vessels and veins, the more 
rapidly the artery contracts. It is, therefore, easy to under- 
stand how the pulsus tardus occurs in pulmonary emphysema, 
arteriosclerosis, lead colic, and in a great variety of diseases 
characterized by severe pain. In reference to the strength of the 
pulse, a hard pulse (pulsus durus) and a soft pulse (pulsus mollis) 
are spoken of. The strength of the pulse is diagnostic from the 
degree of pressure required to prevent the pulse from expand- 
ing. The strength of the heart and the tension of the arterial 
wall are factors in the production of a hard or a soft pulse. 
The beginner must be careful not to confound the hard pulse 
with arterial sclerosis. In the latter condition the pulse feels 
like a whip-cord under the fingers, which is not the case in 
the pulsus durus. The hard pulse is encountered in hyper- 
trophy of the left ventricle ; hence it is found in aortic insuffi- 
ciency and in contracted kidney, in attacks of lead colic and in 
inflammatory conditions, especially in those characterized by 
pain, such as peritonitis. In reference to the size of the pulse, 
we speak of the regular pulse (pulsus equalis) and the irregular 
pulse (pulsus inequalis) ; a full and an empty pulse (pulsus 
plenus and pulsus vacuus) ; a large and a small pulse (pulsus 
magnus and pidsus parvus). 

The Regular and the Irregular Pulse. — In the irregular 
pulse some pulse-waves may be larger than others. Very 
often there is irregularity as to frequency and size. A flat and 
empty pulse may depend upon the walls and the size of the 
lumen of the artery. A large pulse usually occurs in healthy 
individuals during the middle periods of life. The pulse is 
smaller in childhood and in old age. Men have a larger 
pulse than women, and the pulse is larger after meals than 



SPHYGMOGRAPHY OF THE RADIAL PULSE. 43 

before. A large pulse is apt to be slower than a small pulse. 
If anatomic relations of both sides of the body are symmetric, 
the radial pulse will be of even volume and rhythm. If abnor- 
malities of the arteries exist, the pulse is apt to show variation as 
to time and quality (comparing the two sides). The symmetry 
of the .pulse is also influenced by aneurysms, such as of the 
innominate artery, the subclavian, axillary, and the brachial. 
Pressure upon certain arteries may give the same variation — 
from tumors, large pleural effusions, pneumothorax, disloca- 
tion and fracture, enlarged glands, thrombosis, embolism, and 
tumors of the vessel-wall. 



SPHYGMOGRAPHY OF THE RADIAL PULSE. 

The idea of producing the tracings of the pulse originated 
with Vierordt. The instrument used for this purpose is 
known as the sphygmograph. The two instruments that are 
most frequently employed are the Marey and the Dudgeon 




Fig. 1. — Normal pulse-curve in a healthy man aged twenty-five years (after Eichhorst). 



sphygmographs. Sphygmographic tracing records the pres- 
sure of the pulse in the artery, but it must be understood that 
the measurement is only relative and that an absolute measure 
of the size of the pulse or of the internal pressure of the artery 
can not be obtained in this way, as the height of the pulse- 
wave varies with the position of the instrument with reference 
to the artery and the position of the pad that receives the 
tracing of the pulse. It follows from this that very little 
dependence should be placed on the height of the pulse-wave, 
and only the forms should be observed. 

In health the pulse-curve, which is obtained by means of 
the sphygmograph, shows ascending and descending lines, 
elevations, and depressions corresponding with the collapse 
and expansion of the artery. The apex-curve (eg) and curve 



44 SYMPTOMATOLOGY AND SEMEIOLOGY. 

at the base (b), as can be seen in figure I, need no explana- 
tion. The line al is known as the ascension line, which is 
almost perpendicular. The rise follows quickly. The de- 
scent is more gradual and may show several small waves, 
which usually may be differentiated as a decided elevation (r), 
a backward stroke elevation or recoil due to the closure of 
the semilunar valve, and two, occasionally three, or only one, 




Fig. 2.— Pulse-curve in aortic insufficiency (after Striimpell). 

weaker elevation due to the elasticity of the artery (e). The 
line from e' to e" indicates the secondary oscillation or elas- 
ticity of the arterial wall. Some few pathologic forms of 
sphygmographic tracings are characteristic. Thus, the pulse- 
tracings obtained in lead colic or contracted kidney show 
a descending elevation, with several marked elevations or 
smaller back-stroke elevations corresponding with increased 



Fig. 3.— Pulse-curve with marked mitral stenosis (after Striimpell). 

tension in the arterial system. The pulse of aortic insuffi- 
ciency is characteristic. The apex-curve is short and pointed, 
and the descending line is nearly as steep as the ascending 
line, with marked elevations of the elasticity. There is no 
backward stroke elevation in this pulse, due to failure of the 
semilunar valves to close. The pulse-tracing of mitral stenosis 
shows a small, unequal, irregular, frequent pulse. 



SPHYGMOGRAPHY OF THE RADIAL PULSE. 45 

Diagnostic Value of Examination of the Pulse. — For 

practical purposes palpation of the radial pulse is preferable to 
the use of the sphygmograph for diagnosis. Sphygmography 
requires experience, and even then the pulse-tracings may not 
be afccurate. In cases in which there is great doubt as to 
diagnosis the sphygmograph may be employed. There are 
many diseases in which the character of the pulse as trans- 
mitted to the finger is characteristic. In aortic regurgitation 
the pulse is quick, the frequency usually being slightly in- 




Fig. 4. — Pulse-curve in stenosis of the aortic orifice (after Striimpell). 

creased over the normal, usually regular and quicker. There 
are signs of great hypertrophy of the left ventricle, and the 
receding or water-hammer pulse is due to failure of the semi- 
lunar valves of the heart to close completely. In stenosis of 
the aorta the pulse is small, often of slow quality/and regular. 
It is not so voluminous as the pulse of aortic regurgitation 
just described. In mitral stenosis the pulse is small, unequal 
and irregular, and often rapid. In myocarditis there is often 




Fig. 5— Dicrotic pulse (after Eichhorst). 

a small, soft, irregular, and slow pulse. In pericarditis with 
effusion the pulsus paradoxus may be encountered. In febrile 
conditions, especially enteric fever, the dicrotic pulse is an 
important phenomenon. 

Examination of the Veins. — In examination of the veins 
the jugular and cutaneous veins of the body and extremities 
are inspected. Occasionally, when thrombosis takes place, the 
deeper veins of the extremities may become accessible to ex- 
amination. By means of inspection and palpation the degree 



46 SYMPTOMATOLOGY AND SEMEIOLOGY. 

of fullness and the condition of circulation in the veins may be 
ascertained. Venous thrombosis also shows itself by this 
method. Increased fullness of the veins may be either gen- 
eral or local, depending upon the cause, whether it be central 
or due to a peripheral part of the circulation. General in- 
creased fullness is often due to general venous engorgement. 
This condition is most frequently due to disease of the heart 
or lungs. Many of the diseases of the heart that cause an over- 
distention of the venous system may be mentioned : Failure 
of force in the right ventricle ; this may take place particularly 
in failure of compensation in which the right side of the heart 
is the principal chamber affected ; in producing compensation : 
especially is this true in disease of the mitral valve, more 
rarely from tricuspid stenosis and insufficiency. The various 
forms of myocarditis may also give rise to this condition, as 
may also inflammatory and other fluids in the pericardial sac, 
in which cases the stasis may be due to pressure. Diseases 
of the lungs that give rise to this condition are those in which 
the elasticity of the alveolar structure of the lungs is affected, 
particularly in pseudohypertrophic emphysema. If, as is 
very often the case, chronic bronchitis is associated with the 
condition, the right heart is all the more affected, and venous 
engorgement is apt to be the result. Exudation into the 
pleura may cause pressure ; similar pressure may be exerted 
by ascites, meteorism, and large tumors pressing upward. The 
symptom by which this condition (engorgement of the venous 
system) is noted is the prominence with which the veins of 
the neck stand out, especially if the patient be in a recumbent 
posture. There may be cyanosis, edema, transudation of fluid 
in the serous cavities of the body, enlargement of the liver 
and spleen, decreased amount of urine (often containing 
albumin), and constipation. The local fullness of the veins is 
most often caused by narrowing or closure of the venous 
trunk, either from compression or from thrombosis. It fol- 
lows, therefore, that the larger the vessel affected, the more 
extensive the area of abnormal fullness. Fullness of the 
veins of the arm points to compression of the axillary veins, 
most commonly from tumors or from scars following opera- 
tions in the axilla. Engorged veins over one side of the chest 
are often encountered in mediastinal tumors. The veins under 
the skin of the leg are enlarged if there be thrombosis or 
compression of the femoral veins. Both legs may be affected 
as a result of compression of the inferior vena cava, or both 



SPHYGMOGRAPHY OF THE RADIAL PULSE. 47 

iliac veins, as from ascites or tumors. In engorgement of the 
portal vein, which occurs most often from disease of the liver, 
compression, or thrombosis, the cutaneous veins make up the 
necessary collateral circulation. Under such circumstances 
the veins of the abdomen are enlarged, partly extending up- 
ward toward the thorax, and partly downward toward the in- 
guinal region. There may be a distention of veins around the 
umbilicus. This condition has received the name of " caput 
medusae." In marked emphysema there is sometimes great 
enlargement of the small veins of the chest. This also results 
from adherent pleura and pericardium. 

The Influence of the Respiratory Movements Upon Cir- 
culation in the Veins. — The influence of the respiratory 
movements upon the circulation in the veins shows itself in 
prolonged efforts at coughing, and where the return of the 
venous blood is artificially arrested for some time. This can 
be seen particularly in the veins of the neck (jugular veins). 
With every inspiratory movement a diminution in the size of 
the vein is noted, and with every expiration the vein becomes 
more engorged. In some diseased conditions the opposite of 
this is present ; thus, there will be an inspiratory increase and 
an expiratory decrease in the size of the veins of the neck. 
This sign is encountered occasionally in mediastinal tumors. 
The pulsus paradoxus also occurs in this condition. Kuss- 
maul has explained this as due to the traction and bending of 
the large vessels during inspiration. 

The Venous Pulse.^-Pulsation in the veins may depend 
either directly or indirectly upon cardiac action, and is known 
as the venous pulse. It may be transmitted (communi- 
cated) or actually exist in the veins. The latter condition 
is known as the autochthonous or true venous pulse. The 
former is usually due to the pulsation of the carotid artery, 
communicated to the internal jugular. The actual or true 
venous pulse is divided into the so-called normal or negative 
and the pathologic or positive pulse. 

The normal or negative pulse is always presystolic in time, 
and is most often observed in the external jugular. With the 
systole of the heart the vein collapses. If the external jugular 
empties itself with the appearance of the carotid pulse and the 
apex-beat, and fills itself immediately, although slowly, so 
that it attains its complete distention before the following sys- 
tole of the ventricle, it is necessarily presystolic in time. The 
auricle of the heart also has its share in this phenomenon. 



48 SYMPTOMATOLOGY AND SEMEIOLOGY. 

The systole of the ventricle is the diastole of the auricle, which 
favors the flow of the blood from the veins. The auricle begins 
to contract shortly after the beginning of the diastole of the 
ventricle, and thus impedes the flow of the blood from the 
vena cava into the auricle. 

The normal venous pulse is occasionally observed in healthy 
persons. It is, however, small and rarely noticeable. Occa- 
sionally, it becomes stronger, especially under circumstances 
of abnormal fullness of the external jugular vein. 

The pathologic or positive venous pulse occurs synchronously 
with the carotid pulse ; hence it is systolic in time. It is one 
of the most important physical signs in regurgitation of the 
tricuspid valve, being due to the right ventricle causing a 
quantity of blood to regurgitate into the vena cava and its 
adjacent branches from the right auricle, through the im- 
properly closed tricuspid valve. It is most frequently noted 
in the internal jugulars. The veins of the right side of the 
neck show the condition more frequently and to a greater ex- 
tent than do those of the left side. This systolic venous pulse 
is propagated to a certain extent into all the other veins that 
are given off from the vena cava, particularly to the veins of 
the liver, where it manifests itself by a systolic increase and a 
diastolic decrease in the size of the liver — " venous liver pulse." 
In well-marked cases of tricuspid regurgitation the systolic 
venous pulse is noted to a marked degree in this organ. 

Diastolic collapse of the veins occasionally occurs in adhe- 
sive pericarditis. This may be associated with systolic dimp- 
ling at the apex of the heart, a bulging forward of the heart 
in diastole, together with the movement of the anterior wall 
of the chest forward, probably causing the large veins to 
empty themselves of their contents. This was first described 
by Friedreich, and is known as " Friedreich's sign." 

Venous thrombosis occurs in the course of the acute infec- 
tious diseases ; occasionally, it takes place in the aged. It 
is especially a sequel of enteric fever. It occurs most promi- 
nently in the left leg, sometimes in both legs, and rarely in 
the right leg alone. Adventitious sounds, usually of short 
duration, are at times encountered over the jugular and 
crural veins. They are known as murmurs. These com- 
monly take place, as has already been indicated, in tricuspid 
insufficiency. The most marked sign or murmur noticed in 
the veins of the neck has been described as the venous hum, 
venous murmur, nuns 1 murmur, or bruit de diable. This 



EXAMINATION OF THE RESPIRATORY ORGANS. 49 

accompanies conditions of anemia, especially chlorosis ; occa- 
sionally, though rarely, it occurs in health. It is commonly 
louder upon the right side. It consists in a constant regular 
hum. It may have a singing, piping, or musical character, 
and the patient may be aware of this sound. 



PHYSICAL DIAGNOSIS. 

The methods of physical diagnosis consist of inspection, 
palpation, mensuration, percussion, auscultation, and succus- 
sion. The phenomena obtained are mostly objective in nature ; 
hence they are signs, and must be determined through clin- 
ical observation. 

EXAMINATION OF THE RESPIRATORY ORGANS, 

For purposes of convenience the chest may be divided into 
certain almost definite areas. Anteriorly, the supraclavicular 
fossa is noted. This is of importance, as it is the space that 
corresponds to the apex of the lungs. Anteriorly, the lungs 
reach to the sixth rib ; posteriorly, to the tenth ; and nearly 
everywhere they are in direct contact with the chest-wall, ex- 
cept in the neighborhood of the heart and behind a small por- 
tion of the upper part of the sternum ; the apex projects from 
three to five centimeters above the clavicle, the anterior bor- 
ders converging downward so that behind the middle of the 
sternum and a little to the left the lungs come closely into con- 
tact. From this point the inner border of the right lung pro- 
ceeds downward to the top of the insertion of the fifth rib, 
gradually bending toward the right and following the sixth 
rib, and in the mammillary line reaching the upper border of 
this rib. On the left side the lung bends sharply around from 
the fourth rib, giving place to the heart, continuing around 
the fourth rib as far as the parasternal line ; then running 
almost vertically downward, making a small bow and con- 
verging toward the right ; sharply bending behind the sixth 
rib again, so as to cross the mammillary line under the sixth 
rib, being somewhat lower than the right side, and passing 
the axillary line between the seventh and eighth ribs and 
the scapular line at the tenth rib. The space above the clav- 
icle is known as the supraclavicular fossa, the space below 
being known as the infraclavicular fossa. From the second 
rib downward we enumerate the intercostal spaces. Certain 
4 



50 



PHYSICAL DIAGNOSIS. 



artificial lines are drawn upon the chest : first, the median line, 
which is supposed to pass immediately through the middle of 
the sternum ; second, the sternal line, lying upon the right 
and the left border of the sternum ; third, the parasternal line, 
consisting of a line drawn midway between the nipple and the 
sternal line ; fourth, the mammillary line, also called the mid- 
clavicular, a line drawn midway through the center of the clav- 
icle through the nipple 
in males ; fifth, the ante- 
rior axillary line, drawn 
through the anterior ax- 
illary fold ; sixth, the 
midaxillary line, drawn 
through the middle ax- 
illary fold ; and seventh, 
the posterior axillary 
line, drawn through the 
posterior axillary fold. 
These lines run parallel. 
Posteriorly, the spaces 
are known as the su- 
prascapular space above 
the scapula, and the in- 
frascapular space below 
the scapula. The intra- 
scapular space lies be- 
tween the two scapulae. 
The methods gener- 
ally employed in exam- 
ining the respiratory or- 
gans consist of inspec- 
tion, palpation, percussion, and auscultation ; mensuration and 
succussion are of less importance. 

Inspection. — In inspection great stress must be laid upon 
the shape of the chest, the respiratory movements, and the 
frequency of respiration. In inspecting the thorax the light 
should fall upon either the front or the back of the patient, 
depending upon the part to be examined, the examiner stand- 
ing directly in front of the middle line of the body. The 
structure of the chest and neck in reference to peculiarities, 
and the respiratory movements during quiet and deep respira- 
tion, should be carefully noted. In the normal shape of the 
chest the most conspicuous part will be found in the symme- 




Bi 8 2 n £,a. 
3 B <' 



Fig. 6. — Diagram showing artificial divisions 
of the chest (after Eichhorst). 



EXAMINATION OF THE RESPIRATORY ORGANS. 5 I 

try existing between both sides, although even normally there 
may be a slight curvature of the dorsal vertebrae toward the 
right side. The clavicular depressions may be no more than 
indicated, and the angulus Ludovici, also known as the angle 
of Louis (the angle formed by the junction of the manubrium 
and the corpus sterni), may be no more than just recogniza- 
ble. The true ribs must leave the sternum with increasing 
obliquity from above downward, making the costal or epigas- 
tric angle almost a right angle. The normal thorax is well 
developed, the scapula in the upright position lying flat upon it. 
The intercostal spaces are only visible at the lower parts of the 
chest, and the dimensions of the chest and the size of the body 
should have a definite relation to each other. The normal 
number of respirations in the adults are between 16 and 20 a 
minute ; in the new-born about 45 a minute ; and at five years 
of age about 26 a minute. In standing or in sitting respiration 
is somewhat more rapid than in the recumbent posture. It is 
increased by psychic impressions and by exercise. For accu- 
rate counting the hand should be laid lightly upon the chest- 
wall. Normally, the breathing is regular, the respirations 
being of equal length, but under slight nervous influences 
they may become unequal or irregular. In inspiration the 
thorax enlarges, which is due to the elevation of the ribs and 
sternum, to the drawing of the ribs upward and downward by 
the intercostal muscles and by contraction of the diaphragm. 
In expiration the lumen of the chest is lessened. In males 
the type of breathing is almost abdominal, whereas in females 
it is almost thoracic or costal. Normally, inspiration is four 
times as long as expiration. 

Pathologic Forms of the Thorax. — The Emphysematous 
Chest or the Inspiratory Form. — In this form there is a 
symmetric enlargement of the chest, and it is found fre- 
quently in chronic pulmonary emphysema. On account of its 
peculiar shape, it is called the " barrel chest." It is charac- 
terized by an increase of the anteroposterior diameter. It is 
more rounded at all points than normal, and a section of the 
chest would show it to be almost circular. The characteris- 
tics of this type are noticed particularly in the upper parts of 
the chest. The intercostal spaces are widened at the upper 
part of the thorax ; at the lower part of the thorax the wid- 
ening of the interspaces is not marked. The lower intercos- 
tal spaces occasionally are drawn in during inspiration. The 
ribs are at right angles to the sternum ; hence the costal angle 



52 PHYSICAL DIAGNOSIS. 

is greater than the normal right angle and is almost obtuse. 
From this description it will be readily seen that the thorax is 
short. The breathing is typical, the expiration being markedly 
prolonged, and respiration generally being assisted by the 
auxiliary muscles of respiration. In respiration the entire 
chest rises and falls as if it were made of one piece. This is 
due to the rigidity of the chest-wall. Costal breathing does 
not occur. 

A unilateral expansioji of the chest arises in some forms of 
pulmonary disease. It may arise in the course of one-sided 
emphysema of the lungs, which condition occurs when the 
opposite lung has lost its function. In croupous pneumonia 
an enlargement of one side of the chest may take place, or 
this may occur from tumors of the lung. More often unilat- 
eral enlargement of one side of the chest arises from very large 
pleuritic exudations or from pneumothorax or hydropneumo- 
thorax. Circumscribed enlargement of the thorax rarely re- 
sults from circumscribed pulmonary emphysema. Small 
encapsulated exudates from pleurisy, pneumothorax, tumors 
of the pleura, or empyema necessitatis give rise to this condi- 
tion, as do also peripleuritic abscesses. Diseases of the heart, 
especially those which give rise to increase in substance, may 
produce circumscribed enlargement of the thorax. Similar 
diseases of the mediastinum may produce the same condition. 

The expiratory, phthisical, alar, or pterygoid chest is charac- 
terized by a bilateral retraction of the thorax. It is also 
sometimes called the paralytic chest. This form of chest is 
almost always congenital, and occurs particularly in families 
that are subject to pulmonary tuberculosis. But limited 
respiratory effort is possible in a chest of this shape, and so 
it is not difficult to understand why this form predisposes to 
tuberculosis. Some authorities for this reason have claimed 
that it is not so much the lung tissue, but the shape of the 
chest, that predisposes to tuberculous disease. The tubercu- 
lar chest is narrow and flat, especially at the upper part. The 
intercostal spaces are wide : the ribs incline downward from 
the sternum, and are bent at a sharp angle in order to come 
back to the vertebrae. This elongation and sloping from the 
sternum makes the costal angle sharp or almost acute. The 
shoulder-blades stand out like wings ; hence the name, alar 
or pterygoid chest. The anteroposterior diameter is shortened. 

Unilateral retraction of the thorax is due to the resorption 
of pleuritic exudates that have existed for a long time, and in 



EXAMINATION OF THE RESPIRATORY ORGANS. 53 

interstitial disease or shrinking of the lung or pleura the whole 
side may appear to be drawn in, so that the affected side is 
smaller than the healthy one. The ribs are close together, 
and may overlap at the lower part of the chest. The shoulder 
droops ; the nipple and scapula are nearer the median line. 
The vertebral column is curved, with its convexity toward the 
sound side. There is diminished breathing upon the affected 
side or it is entirely absent, the sound side developing com- 
pensatory hypertrophy. 

Funnel-shaped Chest (Trichterbrust). — This may occur in 
two ways : it may be either congenital or acquired. The 
acquired form is due to pressure against the lower part of the 
sternum along the xiphoid cartilage, and is found in many 
occupations, particularly among shoemakers ; hence it is 
sometimes called " Schusterbrust " ; it occurs also from mouth- 
breathing. The congenital form has no particular significance. 

The Irregtdar Chest Forms. — These may be due to altera- 
tion or deformity of the skeleton. Kyphosis, a bending back- 
ward of the spine, scoliosis, a bending sidewise of the spine, 
or, more often still, a combination of both, kyphoscoliosis, 
produces an enormous deformity of the chest. These forms, 
however, belong particularly to the domain of surgery. 

Rachitis or rickets produces deformities of the chest. The 
rachitic chest is characterized by osteoid formations near the 
cartilages where they join the ribs. This has been called the 
" ricket rosary." 

The pigeon- or chicken-breast, in which the chest seems com- 
pressed sidewise and pushed forward, the ribs running sharply 
backward from the front so that the sternum stands out promi- 
nently like the breast of a pigeon or chicken, is a particular 
deformity noticed. 

Harrison's grooves are depressions which merge from the 
ensiform cartilage toward the axilla ; the curve is transverse, 
and may deepen with inspiration. It is often associated with 
the rachitic chest. 

Respiratory Type. — This has already been indicated in say- 
ing that males have the abdominal and females the costal 
type. Occasionally, there is a mixture of these two types, 
known as the costo-abdominal type. Movement of the dia- 
phragm may be noticed in thin persons. It shows itself as a 
light shadow, taking place particularly upon the right side, 
with each inspiration falling downward, and with each expira- 
tion moving upward. The breadth of the excursis is from 



54 PHYSICAL DIAGNOSIS. 

five to seven centimeters. Litten has called this the diaphragm 
phenomenon, and believes it is of great importance to determine 
the lower border of the lungs. Changes in the respiratory 
types may occur : that is to say, the costal type may be 
observed in men, especially where there is disease of the 
abdominal organs or the diaphragm. The abdominal type 
may be seen in women in whom there is disease of the thoracic 
organs. 

Inspiratory Retraction of the Intercostal Spaces. — If the nor- 
mal respiratory movements are carefully noted, it will be seen 
that in quiet breathing, during inspiration the intercostal spaces 
flatten and come forward only to the anterior edge of the ribs. 
No movement beyond this is seen in health. From the fourth 
rib downward, at the beginning of inspiration a decided deepen- 
ing in the intercostal spaces may be observed. Pathologic 
inspiratory retractions occur in diseases in which the atmo- 
spheric air does not gain entrance into the alveolar structure 
of the lungs. This may be due to mechanical causes in 
which obstruction may prevent entrance of air, such as mucus, 
pus, blood, fibrinous exudates, tumors, foreign bodies, inflam- 
mation of the mucous membranes, spasm of the bronchial 
muscles, or disease of the alveolar structure itself. This is 
noticed most prominently in children, and is seen in diseases 
like laryngitis, diphtheria, and croup. If both sides of the 
thorax show retraction, the difficulty is most apt to be in the 
upper air-passages, in the larynx, or in the trachea. Retrac- 
tion of one side of the thorax is found when the principal 
bronchus of the side is affected. This may be due to foreign 
bodies, inflammation, collection of mucus or' inflammatory 
exudates, compression or narrowing, from lymphatic glands, 
mediastinal tumors, aneurysms, or large pericardial or pleural 
exudations. Circumscribed retractions are due to local dis- 
ease, such as the plugging of several small bronchi or alveoli 
of the lung. This occurs frequently in tubercular disease, 
and is usually bilateral. Expiratory bulging of the interspaces 
may take place from narrowing or closure of the glottis, such 
as may result from vomiting, coughing, or asthma. Circum- 
scribed bulging is noted in pulmonary emphysema, giving the 
chest the appearance already described as the inspiratory form". 

Intensity of the Respiratory Movements. — Sibson has 
called attention to the fact that the right side of the chest ex- 
pands slightly more than the left. This condition has been 
attributed to the greater development of the muscles upon the 



EXAMINATION OF THE RESPIRATORY ORGANS. 55 

right side, the greater width of the right bronchus, and the 
larger size of the right lung. In sleep the respiratory move- 
ments are slightly less frequent. Bodily exercise and psychic 
influences produce an increase in the respiratory functions. 
These conditions are all considered as physiologic. Dimin- 
ished respiratory movements are seen in pulmonary emphy- 
sema and in tubercular disease of the lungs, but if complica- 
tion occurs, such as bronchitis, an increase in the respiratory 
movement may be seen. In fainting (syncope) diminished res- 
piratory movements are noted. A unilateral diminution in the 
respiratory intensity may be observed in diseases of the bronchi, 
if the free access of air in reaching the alveolar structure of 
the lungs is prevented. This is especially noticeable if foreign 
bodies gain entrance to the air-passages. The same condition 
is often associated with disease of the alveolar structure of the 
lung, especially if the alveoli contain inflammatory masses or 
the lung is the seat of miliary tuberculosis. In disease of the 
pleura this condition is observed. Increased frequency of res- 
piratory intensity takes place in all cases in which the change 
between oxygen and carbonic acid is hindered. Disturbances 
of respiration, due to diseases of the heart, associated with 
stasis in the pulmonary circuit, and disease of both of the 
large bronchi may cause the condition. In paralysis of the 
phrenic nerve, in inflammation of the pleural or peritoneal lin- 
ing of the diaphragm, from meteorism from tumors or from 
accumulation of fluid in the abdomen, the condition may occur. 

The Respiratory Rhythm. — In health there is a regular 
change in the contour of the chest between inspiration and 
expiration. This is known as the respiratory rhythm. Dimin- 
ished frequency of respiration results from many diseases of 
the brain and its membranes ; hence the condition is found in 
meningitis from pressure of tumors or large hemorrhages 
(being associated with some dullness of intellect), even pass- 
ing into the so-called " Cheyne-Stokes respiration." Dimin- 
ished breathing further arises in the acute infectious diseases, 
and finally it is always noted in the death agony. 

Cheyne=Stokes Respiration. — In this form, a group of 
respirations alternate in intensity and rapidity regularly, with 
a more or less well-defined and prolonged pause. A pause in 
respiration is known as apnea. The change from one condi- 
tion to the other is gradual. Beginning and terminating with 
shallow breathing (the patient in the majority of cases being in 
coma), the respirations have a snoring or snorting character. 



5 6 PHYSICAL DIAGNOSIS. 

The pause in the respirations may last from a few seconds to a 
minute or longer. The number of respirations that occur 
before the pause also vary. Most frequently there are from 
eight to twelve. Besides the well-marked form just described, 
there are some less striking varieties. Occasionally, the pause 
or apnea may be missing, and the respiration may not be so 
deep. This form of respiration is very likely to be observed in 
diseases of the brain, from disturbances of the circulation, or 
from toxic conditions. Cheyne -Stokes respiration is always a 
symptom of exceeding gravity. The explanation of this form 
of peculiar breathing has not been satisfactorily determined ; 
it is sometimes accompanied by cyanosis. The duration of 
the Cheyne-Stokes respiration varies considerably. It may 
last for days or even for weeks. Cases have been recorded in 
which the duration has been noted for seven months. 

Difficult Breathing, or Dyspnea. — If the respirations be 
labored, whether the number be normal, prolonged, or more 
frequent, the condition is spoken of as dyspnea, especially if 
the breathing is labored or rapid so that there is an interfer- 
ence with the exchange of gases in the pulmonary circuit, ft 
may also be due to an increased formation of C0 2 , occurring 
in fevers. Dyspnea occurs in stenosis of the upper air-pas- 
sages, from intratracheal tumors, foreign bodies, inflammation, 
cicatrices from ulcers or strictures, and from paralysis of the 
laryngeal muscles, which produce a narrowing of the air- 
passages. Dyspnea often occurs from diseases of the brain, 
and the acme or height of the Cheyne-Stokes respiration is 
practically dyspnea. Expiratory dyspnea takes place com- 
monly in bronchial asthma, in pulmonary emphysema, and 
in disease of the diaphragm. Ordinarily, the dyspnea is both 
inspiratory and expiratory. Dyspnea is a common symptom of 
fever, especially in persons of neurotic temperament. It occurs 
in diseases that are accompanied by pain, such as croupous pneu- 
monia, pleurisy, inflammations of the diaphragm or peritoneum, 
fracture of the ribs, muscular affections of the thorax, disease 
of the bronchial tubes, particularly those that show a tendency 
to narrowing or stenosis, as has already been pointed out in 
asthma, occasionally in forms of bronchitis (croupous bron- 
chitis), and in bronchopneumonia. Various diseases of the 
lungs give rise to the condition, such as pneumonia, edema, in- 
farcts, emphysema, tuberculosis, pleurisy with effusion, pneu- 
mothorax, tumors of the lung and pleura, abdominal affections 
that show a tendency to push the diaphragm upward, in de- 



EXAMINATION OF THE RESPIRATORY ORGANS. 57 

formities of the chest, such as kyphoscoliosis, paralysis of the 
respiratory muscles, as in tetanus and epilepsy, and is some- 
times due to disease of the heart in which the pulmonary cir- 
cuit is interfered with, particularly in disease of the left heart. 
When dyspnea becomes extreme, it is known as orthopnea. 
The symptoms of this condition are usually great anxiety, a 
peculiar expression of the eyes, protrusion of the eyeballs, 
cyanosis, cold sweat, and exceedingly rapid respiration, so 
that the patient must often assume the erect posture. 

Palpation of the Respiratory Organs. — This can only be 
carried on indirectly, as obviously only the thorax and the 
neck, which corresponds to the beginning of the trachea, may 
be directly palpated. On the one hand palpation confirms the 
results of inspection ; it has also an independent value, as 
some signs are discovered upon palpation that can not be 
noted upon inspection. In palpation we notice first the move- 
ments of the chest, the resistance, the presence of pain upon 
pressure, either localized or general, fluctuations of the chest, 
the vocal fremitus, friction fremitus, and palpable rhonchi. 
Palpation of the respiratory excursis should be tested by laying 
the hands flatly upon each side of the chest, first ante- 
riorly and then posteriorly. In this way it will be noticed 
whether one side of the chest expands better than the oppo- 
site. It is also well to place the hands posteriorly in the 
axillary line at the bases of the lungs, in order to notice the 
expansion in this region. The greatest changes in resistance 
may be found in the young, in whom the thorax is compressi- 
ble. Quite the opposite is true in the aged, as great resistance is 
here encountered upon attempts at compression. This is due 
to the calcareous change of the cartilages of the ribs. Patho- 
logically, there is an early tendency to greater resistance of 
the thorax in tubercular disease of the lungs. This some- 
times is not without its value in diagnosis. The emphysema- 
tous chest shows great resistance upon attempts at compression, 
as does also the rachitic thorax. Pain upon palpation is of 
great value in diagnosis in diseases of the chest. The painful 
region may be mapped out with some degree of accuracy by 
feeling each intercostal space with the finger, and deter- 
mining which one of them is tender upon pressure. In this 
way it may be determined whether the pain radiates or not. 
Pain is found in all diseases of the chest in which the pleura 
is implicated ; thus, it is common in the first stage of pleuritis, 
in croupous pneumonia, and in pulmonary tuberculosis in 



58 PHYSICAL DIAGNOSIS. 

which the pleura is involved. It must also be noted whether 
pain is due to involvement of the rib, from caries, or from fracture. 
Myalgia of the chest muscles may also produce pain, espe- 
cially in the superficial muscle. Pleuritic pain and intercostal 
neuralgia are sometimes quite difficult to differentiate. (The 
differential diagnosis between these two conditions has been 
given under Pleurisy.) Abscesses within the chest or in the 
pleura may also cause pain from pressure. Fluctuation upon 
palpation in the region of the thorax is rare. It may occur 
from diseases of the lung in which pus has bored its way 
through to the chest-wall, or from the breaking through of an 
empyema (empyema necessitatis). An important sign to de- 
termine whether the fluctuation be due to disease of the lung 
or pleura or to external lesions will be found in the fact that 
slight pressure may cause the fluctuation to disappear, and 
coughing reproduce the fluctuation, these signs indicating 
intrathoracic disease. 

Vocal or Pectoral Fremitus. — If the flat hand be laid 
upon the thorax and the voice be used, a peculiar quick trem- 
bling or vibration will be communicated to the hand with the 
beginning of the first spoken word and will cease with the use 
of the voice. This palpatory phenomenon is known as vocal, 
pectoral, or tactile fremitus. It is produced by the vocal 
cords being thrown into vibration, the sounds produced being 
carried down from the larynx into the thorax, through the 
bronchi into the alveolar structure of the lung, and thence 
communicated through the chest-wall to the palpating hand. 
The following conditions in reference to vocal fremitus must 
be noted : The louder the voice is used, the more powerful 
and distinct the vocal fremitus. The vocal fremitus is pro- 
portionately plainer the deeper the voice. As males usually 
have a louder voice than females, the vocal fremitus is com- 
monly stronger in the male than in the female sex. It 
follows that when the whispered voice is used, the vocal 
fremitus is very much diminished or even entirely absent. It 
must be further noted that vocal fremitus upon the right side 
at the apex of the lung is more distinct than upon the left. 
This depends upon the fact that the right bronchus is larger 
and is more superficially situated than the left. Finally, vocal 
fremitus depends upon the structure of the thorax — in a thin 
thorax with very little adipose tissue vocal fremitus will be 
more distinct and stronger than where the chest is developed 
by muscle and cutaneous fat. The lower the pitch, — that is 



EXAMINATION OF THE RESPIRATORY ORGANS. 59 

to say, the slower the vibrations, — the more distinct the vocal 
fremitus. In children the vocal fremitus is not so distinct, as 
the vibrations of the voice are too rapid. 

Pathologic Changes in the Vocal Fremitus. — Vocal 

fremitus may be increased, diminished, or absent. Diseases 
of the pleura usually decrease the vocal fremitus. Diseases 
of the lung, on the other hand, usually give increased vocal 
fremitus ; however, many circumstances may influence these 
conditions. In consolidation of the lung the vibrations 
are transmitted with greater force to the hand, producing 
increased vocal fremitus ; thus, we have an increase in pneu- 
monia, tuberculosis, and hemorrhagic infarct. Two condi- 
tions may influence this : if the main bronchus of the con- 
solidated part be occluded, the vocal fremitus will be absent, 
as vibrations can not reach the part ; or if a pleural effusion 
be present over the same area, vocal fremitus is apt to be 
diminished or absent, as fluid does not conduct sound so 
readily. Diminished vocal fremitus results from any cause 
that increases the distance between the lungs and the sur- 
face of the chest, interfering with the conduction of vibra- 
tions ; thus we have diminished vocal fremitus from thickened 
pleura and from small pleural effusions. If the collection of 
air in the bronchi is lessened from a diminution in the caliber 
of the tube, as may occasionally occur in emphysema or 
asthma, or if there be pulmonary cavities filled with fluid, 
vocal fremitus is diminished. Absent vocal fremitus is pro- 
duced by occlusion of the bronchus from external pressure, 
such as tumor, aneurysm, or enlarged gland, or from an accu- 
mulation of large quantities of air or fluid in the pleura ; 
hence vocal fremitus is absent in large pleural effusions, pneu- 
mothorax, hydropneumothorax, and allied conditions. The 
same condition practically exists when the pleura is greatly 
thickened. Marked dilatation of the bronchial tube, especially 
if superficially situated, produces increased vocal fremitus. 
This may occur from bronchiectasis. The same is true of 
a pulmonary cavity, superficially situated and empty. There 
is a sound occasionally produced by the passage of air 
through fluid in the bronchial tubes that is transferred to the 
hand when laid upon the chest. These vibrations are known 
as rlwnclii. They occur particularly during inspiration, and 
take place in such diseases as bronchitis and asthma. They 
may be either coarse or fine. Occasionally, there are localized 
areas of vibration in pulmonary tuberculosis. This is due to 



60 PHYSICAL DIAGNOSIS. 

the passage of air through fluid in the cavity. In bronchitis 
of children, rhonchi are very apt to occur. The tracheal rale 
occurring in the death agony is an example of a rhonchus. 
Vibrations may be transmitted to the hand from inflammation 
of the pleura. They are often felt only during inspiration, but 
may occur during inspiration and expiration, and rarely only 
during expiration alone. At the bases of the chest, either ante- 
riorly, posteriorly, or laterally, they are increased by deep inspi- 
ration, and are not influenced by coughing. Rhonchi, on the 
other hand, may disappear entirely upon coughing or deep 
breathing. Occasionally, upon palpation, if the hand is placed 
over a large cavity containing air and fluid, the splashing (the 
equivalent of succussion) is felt. This takes place almost exclu- 
sively from hydropneumothorax. Under rare circumstances, if 
there is a large pulmonary cavity partially filled with a thin 
secretion, a similar sound maybe noted. Crepitation is some- 
times transmitted to the hand upon palpation. It results from 
subcutaneous emphysema. The same condition is noted from 
prolapse of the lung, but this is a surgical disease. Finally, 
pulsation of the thorax takes place upon palpation. If the 
pulmonary tissue in the immediate neighborhood of the heart 
becomes airless, the cardiac systole is transmitted to the hand 
upon the left side at the base in the form of pulsation. 
Graves first called attention to this in hepatization of the 
lung in croupous pneumonia. Carcinoma may produce the 
same condition. In left-sided empyema, and especially from 
empyema necessitatis, pulsation is transmitted to the hand, 
known as " pulsating empyema." Rarely, pulsation may 
occur upon the left side from a serous exudate, Traube and 
Frantzel having called attention to this fact. Peripleuritic 
abscesses in the neighborhood of the heart may also give rise 
to pulsation upon palpation. 

Mensuration of the Thorax. — The measurement of the 
diameters of the chest has but slight diagnostic value, princi- 
pally because the 'individual variations are so great and the 
eye is usually sufficiently competent to estimate the differ- 
ences better perhaps than any instrument. Cyrtometry 
has for its purpose the determination of the shape of the 
chest. For this purpose pliable media, usually of lead, are 
used, which are molded around the chest, and afterward re- 
moved and drawn upon paper. This method gives but limited 
results ; hence mensuration is not in general practical use. 



EXAMINATION OF THE RESPIRATORY ORGANS. 6 1 

Percussion of the Respiratory Organs. — Percussion has 
for its object the determining of the physical condition of 
the respiratory organs. This is done by means of striking 
upon the chest. The method was first used about the 
year 1761 by Auenbrugger, a Viennese physician, and was 
further improved by Corvisart, the physician of Napoleon, 
being still further studied by Skoda and Traube. Two con- 
ditions are noted upon percussion : (1) that sounds are pro- 
duced and (2) resistance is determined. The sounds pro- 
duced may either produce a musical tone, or they may be 
nothing more than a noise, the vibration of which can not be 
definitely determined, there being no uniformity. Sounds 
have certain well-defined characters : they consist of pitch, 
volume, duratioii, and quality. The pitch is due to the rapidity 
of the vibrations. It may be either high or low, as the vibra- 
tions are rapid or slow. The volume (intensity) depends upon 
the amplitude of the vibration, and varies directly as the 
square of the amplitude of vibrations. It is further modified 
by the amount of force used in producing the sound. Dura- 
tion simply means the period of time taken up in the produc- 
tion of sound. Notes or sound, high in pitch, are of dimin- 
ished volume and of short duration. Sounds low in pitch 
are of increased volume and of long duration. The three 
conditions just described determine the quality. Clearness is 
the term used to designate sounds without the character of 
tones or notes. They are of good volume, long duration, and 
low in pitch. A didl sound is of high pitch, of small volume, 
and of short duration. Irregular sounds or noises in which 
pitch, volume, or duration can not be definitely determined 
are described as flat ; absolutely flat sounds are characterized 
by entire absence of air. The dull and clear sounds are 
alone produced over structures containing air. Areas in which 
there is a definite relation between air and solid material pro- 
duce sounds that vary between clearness and dullness. Reso- 
nance and tympany are modifications of clear sounds. 

Method of Percussion. — The thorax maybe tapped directly 
by the hand or finger. This method is known as immediate 
percussion, and was the method originally employed. It is, 
however, no longer in general use. The general practice 
consists of employing some medium to intervene between the 
surface of the chest and the instrument used for striking or 
percussing. The medium has received the name of pleximeter, 
and the method is called mediate percussion. The pleximeter 



62 PHYSICAL DIAGNOSIS. 

may consist of a small piece of bone or ivory, sufficiently 
small to fit between the ribs, or, what is better, the fingers 
of the hand may be used for this purpose. The instrument 
used in striking to produce the sound is called the plexor. 
This may be a small hammer of moderate weight, with a 
slightly flexible handle, consisting of a metal or rubber mal- 
let. Far better for this purpose are the fingers of the hand, 
as with them an idea of resistance is also obtained, which is 
impossible in the use of the pleximeter and plexor. 

Method Employed in Percussion. — The pleximeter or 
finger must be placed in direct apposition to the surface of the 
chest, and no air must intervene between the medium and the 
chest-wall. The finger should be placed parallel with the 
ribs, but should not cross them. Corresponding areas of the 
chest upon the right and left side should be percussed alter- 
nately. The use of the finger as plexor requires some prac- 
tice. Ordinarily one finger, preferably the middle one, is 
used, but sometimes two fingers are employed. The finger 
should be bent at right angles and retained in a fixed position, 
and it should strike the pleximeter perpendicularly to its 
plane (at right angles). The force of the blow should be 
regular and even, and must come fro?n the wrist alone. An- 
teriorly, percussion should be begun in the supraclavicular 
fossa, proceeding downward from interspace to interspace, and, 
as has already been stated, comparisons being made with the 
opposite side. Next, the axillary portions and, finally, the 
posterior portions of the chest should be examined in the 
same way. To perform percussion properly, the patient should 
be in the erect posture, with the arms held loosely at the sides. 
No position should be chosen that would draw the chest 
muscles into contraction. When the posterior aspect of the 
chest is examined, it is well to have the patient fold his arms 
and bend slightly forward. This separates the scapulae more 
widely and allows more freedom of access to the interscapular 
spaces. It is well to remove all clothing if practicable. A 
thin, loose garment may be used from motives of delicacy, or 
only parts of the chest should be exposed if there is any 
possibility of chilling the surface of the body. 

Normal Percussion. — Three qualities of sound are devel- 
oped over the normal thorax by percussion. Tympany is 
elicited over the trachea, resonance over the lungs, and dull- 
ness over the cardiac area. By resonance is meant a clear 
sound produced over the normal lung tissue, being due to the 



EXAMINATION OF THE RESPIRATORY ORGANS. 63 

vibration of the chest-wall and of the air in the various bron- 
chial tubes. The term normal pulmonary resonance or vesic- 
ular resonance is used to designate the same condition. The 
note called resonance can scarcely be described as a tone, as 
the relation of air being confined in innumerable small sacs in 
the solid structure of the lungs prevents tone formation, and 
the vibrations do not occur in unison. It is preferable to use 
the term clearness or resonance. Normal pulmonary reson- 
ance is developed at various parts of the chest. Its most 
defined type is encountered in the upper axillary region behind 
the angle of the scapula, and on the anterior surface of the 
chest in the second interspace. It is somewhat higher in pitch 
at the right apex than at the left. Accumulation of adipose 
tissue and thick muscular chest-walls impair resonance, and 
require deeper percussion. The elasticity of the chest also 
bears some relation to the quality of the note encountered. 
In old age with rigid chest-walls the note is less clear than 
in children. It should be remembered that in percussing 
upon the left side of the chest below the third rib dullness 
is elicited, which is due to the presence of the heart. If the 
note be more than clear, having a higher pitch, it is usually 
due to an excess of air, the condition being called hyper- 
resonance. If the note be less clear, there is a diminution in 
the amount of air, or an increase of the solid structure, and it 
is spoken of as impaired resonance. Tympany is present 
in percussion over a cavity with smooth walls containing air, 
in which the sound is low in pitch, of considerable volume, 
and of long duration. In health it can only be elicited over 
the trachea, over the stomach when it is empty, and over the 
large and small intestines. It sometimes possesses a metallic 
quality. Tympany may sometimes, though rarely, be elicited 
normally over the posterior portion of the lungs in children 
and infants. It differs from resonance in being lower in pitch, 
smaller in volume, and shorter in duration. For practical pur- 
poses it may be stated that resonance comes midway between 
tympany and dullness. The larger the amount of air present, 
the greater the tympany. The sound in percussing over the 
heart is termed dull. It shows the absence of air. It is 
necessary in percussion to estimate the pitch of the sound 
elicited. This is quite difficult to do, and requires consider- 
able practice. Under normal circumstances, the sound under 
the right clavicle is higher in pitch than the sound under the 
left, but it can not be spoken of as being dull in character. 



64 PHYSICAL DIAGNOSIS. 

Generally speaking, a high-pitched note is considered a dull 
note. Change in pitch makes it possible at times to outline 
particular organs. 

Degree of Resistance. — This can only be ascertained by 
the sense of resistance communicated to the finger. Over 
organs containing air, the resistance is slight. The sensation 
imparted to the finger is as if the parts recede and yield. As the 
quantity of air becomes less and less, and approach is made to 
solid structure, resistance becomes proportionately increased, 
until with an entirely airless structure it is great. Finally, a 
difference must be made between superficial and deep percus- 
sion. In superficial percussion a note is obtained of that por- 
tion lying directly beneath the part percussed. Superficial 
percussion is light percussion. In deep percussion the blows 
are delivered with force, and the sound of structures deeply 
situated is elicited in this way. By auscultatory percussion is 
meant that percussion is carried on while the stethoscope is 
placed at some slight distance. In this way the borders of an 
organ may be outlined. Mediate percussion may be used for this 
purpose. Percussion has for its object the determination of 
the size of the lungs, the presence or absence of abnormal 
sounds so that the physical condition may be ascertained, and 
the apparent size of organs in the chest noted (topographic 
percussion). The normal boundaries of the lungs have already 
been given. An increase in size takes place in pulmonary 
emphysema. A diminution in size may occur at one or both 
apices, as in pulmonary tuberculosis and in adherent pleura, 
and also in other diseases of the lung. 

Abnormal Percussion Sounds. — Disease of one or both 
apices is recognized by impaired resonance. If the resonance 
at the left apex should be as high in pitch as that at the right, 
it would show implication of the left apex. Dullness is due to 
the formation of solid new growths in the air structure of. the 
lung, or to the development of fluids in the air-cells and tubes. 
It may also be due to the medium that obscures the sound of 
the lung between it and the finger. It occurs in diseases like 
croupous pneumonia, bronchopneumonia, tuberculosis of the 
apices, large hemorrhagic infarcts, and solid tumors. Under the 
second heading the pleural exudate plays the chief role. This is 
found at the lower part of the chest, and dullness or, more cor- 
rectly speaking, flatness, occurs as high as the level of the fluid. 
If the amount of the effusion be very large, it may even extend 
to the apex. A transudate into the pleural cavity also produces 



EXAMINATION OF THE RESPIRATORY ORGANS. 65 

flatness at the base (hydrothorax). Great thickening of the 
pleura also produces impaired resonance, and it is sometimes 
very difficult to determine between a small pleural exudate 
and a thickened pleura. Finally, in processes that thicken 
the chest-wall, such as tumors or edema, impaired resonance 
or even complete dullness or flatness is produced. In con- 
solidated lung and in fluid in the pleural cavity above the level 
of the fluid and above the level of the consolidation a high- 
pitched, somewhat tympanitic (hyperresonant) note is encoun- 
tered called Skodaic resonance. The note is short, the tone is 
clear, and the pitch is raised. Skodaic resonance is due to con- 
solidation or an accumulation of air above the layer of fluid. 
The tympanitic sound occurs abnormally if there is an in- 
creased amount of air in any part of the lung or bronchial 
tube. It may result from retraction of the lung, or from 
shrinkage due to any cause ; hence it may take place from 
pleuritic exudation, tumors, pericardial effusion, rarely from 
hypertrophy and dilatation of the heart, or from pressure be- 
neath the diaphragm. It is known as relaxation of the lung 
tissue. Marked shrinking or thickening of the lung produces 
a tympanitic note like percussing over the trachea. This has 
been called "Williams' tracheal sound." It takes place from 
pulmonary cavities (vomicae). If the cavity is empty and 
is superficially situated and communicates with the bronchus, 
the "cracked-pot" sound is elicited. To produce this the 
patient should have the mouth open, and the area in which 
the cavity occurs should be sharply and firmly percussed. 
The sound may be imitated by placing the two hands lightly 
together and striking them against the knees. If the cavity is 
large, with smooth walls, a metallic quality may be added to 
the tympanitic resonance. If the cavity is covered by thick- 
ened lung tissue or pleura, a note of decided tympanitic 
quality is encountered. This is sometimes spoken of as dull 
tympany. As the cavity becomes filled with fluid the tym- 
panitic note gradually gives way to dullness or flatness. The 
tympanitic sound becomes more distinct, louder, and higher 
in pitch if the patient opens the mouth wide. This is noted 
particularly in cavities that communicate with the bronchus. 
This is known as "Wintrich's change of sound." Finally, 
the tympanitic note occurs in pneumothorax. An abnormally 
loud and deep sound takes place in severe pseudohypertrophic 
emphysema. In pneumothorax the tympanitic note often has 
a metallic quality added. Flatness occurs only over organs 
5 



66 PHYSICAL DIAGNOSIS. 

entirely devoid of air, such as the liver, or in percussion over 
the thigh and over extensive accumulations of fluid. 

Auscultation of the Respiratory Organs. — This is one 
of the earliest methods of examination, Hippocrates having 
described certain auscultatory phenomena, particularly the suc- 
cussion sound. Pleuritic friction and certain rales appear to 
have been known in ancient times. The method, however, 
was neglected until about the beginning of the nineteenth 
century, when Laennec, about 1819, called attention to aus- 
cultation by his thesis published in Paris. The development 
of auscultation, as in fact nearly every method of physical 
diagnosis, we owe particularly to the studies of the Viennese 
physician, Skoda. As in percussion, so in auscultation, there 
is an immediate and a mediate method. In the first method 
the ear is laid directly against the chest-wall, whereas in the 
last method an instrument known as the stethoscope is 
used. Laennec himself practised the stethoscopic method. 
In auscultation without the use of the stethoscope the phe- 
nomena appear louder, and a larger part or portion of the 
thorax can be examined than by means of the . stethoscope. 
This should be remembered in the examination of feeble and 
weak individuals in whom a rapid examination of the chest is 
necessary. The stethoscope becomes of special value when 
it is necessary to localize certain auscultatory phenomena. It 
is of especial importance in the examination of the heart and 
the large vessels. It is furthermore noteworthy that there are 
several portions of the chest that are not accessible to the ear 
directly, and that can only be examined by the stethoscope. 
The supraclavicular fossa, the examination of which is espe- 
cially important in tubercular diseases of the lungs, is an 
instance of this. There are decided disadvantages in the use 
of the immediate method, as in the examination of unclean, 
perspiring patients, those affected with skin diseases, etc. 
In such cases it is better to use a towel. Care must be 
taken that there are no folds in the towel, and the ear must 
be placed against the thorax. Auscultation is valueless 
if it is undertaken over a number of garments, as so many 
extraneous sounds are produced as to render the value of 
the method unimportant. From what has been said it may 
be gathered that it is impossible to do without stethoscopic 
auscultation. Stethoscopes have been improved ever since the 
method of auscultation came into general use. At first they 
consisted of a solid piece of wood. These were used by 



EXAMINATION OF THE RESPIRATORY ORGANS, 6j 

Niemeyer and Quincke. But to-day they are either the 
double stethoscope, after the model of Camman, or the single 
stethoscope. In using it it is well to remember that the in- 
strument should be placed on the bare chest and not over 
clothing. In auscultating the chest the following points must 
be carefully noted : the character of the respiratory murmur, 
which may be of a vesicular, bronchial, or mixed type ; the 
presence of rales, whether dry or moist ; the presence of 
pleural friction sound, and the auscultation of the voice. 

Vesicular Breathing. — In auscultation of the sound lung, 
at almost all parts of the thorax, normal vesicular breathing is 
noted. It is heard almost exclusively in inspiration, whereas in 
expiration an indistinct or slight blowing sound, which is 
more of the character of bronchial breathing, is noted. The 
expiration is lower in pitch than the inspiration, but not 
so loud. Vesicular respiration may be imitated by almost 
completely closing the mouth and leaving only a small cleft, 
and then with some force drawing air into the buccal cavity ; 
or the lips may be put in position as if to pronounce the con- 
sonants "v" and "f," and air drawn into the mouth. This 
illustrates very well the character of normal vesicular breath- 
ing. The character of its production is by no means settled. 
Laennec suggested that it occurred from friction of the inspir- 
atory stream of air against the wall of the bronchial tubes and 
the infundibula of the lung. Several other theories have been 
given for the production of this sound, the most likely of 
which, however, are those advanced by Baas and Penzoldt, 
that vesicular breathing is produced by the column of air en- 
tering through the larynx and into the bronchus, producing 
bronchial breathing, and which, traveling further through the 
lungs, loses its bronchial character as the sound becomes 
disseminated and is changed into the vesicular murmur. The 
recognition of vesicular breathing is of importance. It shows 
that the alveoli and the finer bronchi are still capable of admit- 
ting air. Care must be taken, however, to remember that in 
certain diseased conditions of the lung a few air vesicles may 
yet be capable of receiving inspired air, and thus the vesicular 
murmur be produced. This sometimes takes place in broncho- 
pneumonia and in miliary tuberculosis. In superficial cavities 
in which, as a rule, bronchial breathing is heard, vesicular 
breathing may occur, which can not be explained in any other 
way than that the alveolar structure surrounding the cavity is 
still capable of admitting air. The following points must be 



68 PHYSICAL DIAGNOSIS. 

noted in reference to vesicular breathing : the force, the 
strength or intensity, and the interrupted vesicular breathing. 
The strength of vesicular breathing depends upon age and sex. 
Children and women usually show more pronounced vesicular 
breathing than men. This depends particularly upon the 
smaller lumen of the larynx, giving a higher pitch than the 
larger male larynx. In old age vesicular breathing is often 
found to be intense. In general miliary tuberculosis and in 
edema of the lungs strong, high-pitched vesicular breathing is 
often noted. 

Strength and Intensity of the Vesicular Murmur. — In 
superficial respiration the character of the vesicular murmur 
is often indistinct and not at all well characterized. The 
intensity of the vesicular murmur in health then depends 
upon the force of the inspiratory movement and the thickness 
of the thorax. Deep inspiration and coughing or crying, 
especially in children, show a well-developed type of the 
vesicular murmur. In Cheyne-Stokes respiration the more 
superficial the respiratory movement, the more indistinct is the 
vesicular murmur ; whereas the deeper the respiration, the 
more developed the vesicular murmur becomes. The thick- 
ness of the walls of the thorax has an important influence 
upon the character of the vesicular murmur. Thus, in well- 
developed muscular chests the vesicular murmur is not pro- 
nounced except upon very deep inspiration. In thin chests, 
on the contrary, the vesicular murmur is often well marked. 
In the erect posture it is often more pronounced than in the 
recumbent posture. After meals and after moderate exercise 
the vesicular murmur is more distinct, whereas in sleep and in 
weak individuals it is not well characterized. Laennec called 
attention to the fact that from the use of tight corsets the 
vesicular murmur becomes stronger at the apices ; women 
therefore show a stronger and more pronounced vesicular 
murmur than men. As a rule, the vesicular murmur is better 
heard upon the left side of the chest than upon the right. 
Normally, the vesicular murmur is stronger upon the upper 
anterior surface of the chest. It is less distinct posteriorly 
and in the axillary regions. It is loudest directly beneath the 
clavicles. It progressively diminishes in intensity as the lower 
parts of the thorax are reached. It is furthermore noteworthy 
that in the spaces between the parasternal and mammillary line 
the murmur is more intense than at the sternal border and 
in the neighborhood of the axillary line. Over the sternum 



EXAMINATION OF THE RESPIRATORY ORGANS. 69 

itself the vesicular murmur is plainly heard, due to transmis- 
sion. It is better marked at the upper parts than at the lower 
parts of the sternum. In the axillary line the murmur is 
more intense at the upper than at the lower parts of the chest. 
In the scapular regions the murmur is not well developed ; this 
is particularly due to the great thickness of the muscles. When 
the vesicular murmur becomes stronger and more sharply de- 
fined, it may be imitated by placing the lips in the position of 
pronouncing the consonant " f," and drawing air into the 
buccal cavity, which is the usual form of respiratory murmur 
heard in children ; this is known as puerile respiration. It is 
of higher pitch than the normal vesicular murmur found in 
adults, and it is found occasionally in chests with very thin 
muscular walls. Diminished vesicular breathing occurs from 
narrowing of the lumen of the bronchial tubes themselves, 
inflammation of the mucous membrane, fibrinous exudates, 
tumors, foreign bodies, or compression of the tubes. The 
vesicular murmur is further diminished, or may be entirely 
absent upon the surface of the thorax, by accumulation of 
fluid or gas in the pleural cavities. Diseased conditions of the 
walls of the thorax, such as edema, or well-developed adipose 
tissue may give rise to a diminution in the respiratory murmur. 
Diseases that produce pain and in which breathing is dimin- 
ished may show a lessening in the respiratory murmur, such 
as pleuritis, myalgias of the intercostal muscle, thickening of 
the pleura ; and it is particularly found in chronic pulmonary 
emphysema. In the latter case the diminution of the respir- 
atory murmur is due to the loss of elasticity in the alveolar 
structures of the lung. Diseases of the upper air-passages 
may also produce diminished or absent vesicular murmur : 
diphtheria of the larynx, paralysis of the posterior crico- 
arytenoid muscles, and paralysis of the muscles of one side 
of the chest are examples. Pathologic increase of the ves- 
icular murmur is invariably associated with an increased and 
quickened respiratory movement. It is often found in nervous 
and hysteric women. It is almost invariably associated with 
febrile diseases. In all conditions in which one lung is entirely 
or "for the most part diseased the opposite lung takes on extra 
function. In such a case an increased vesicular murmur is 
noted, which is spoken of as vicarious, supplementary y or com- 
pensatory breathing. Bronchitis often increases the intensity 
of the vesicular murmur. A sign of great diagnostic import- 
ance is the increased and more powerful vesicular murmur of 



yO PHYSICAL DIAGNOSIS. 

the apices of the lung, this condition being very commonly 
associated with pulmonary tuberculosis. This sign is of espe- 
cial importance should it occur at both apices. Wintrich first 
called attention to a systolic vesicular murmur. This is fre- 
quently found in normal healthy persons at the margin of the 
lungs where they come in contact with the heart. It follows 
from this that it is more frequently observed upon the left than 
upon the right side. It is an acoustic phenomenon that the 
vesicular inspiratory murmur is rhythmically strengthened 
with the systole of the heart, and is decreased or even becomes 
inaudible with diastole. Interrupted vesicular murmur shows 
itself through a break in the continuity of the inspiratory 
sound. It is occasionally heard in children from fear, espe- 
cially during an examination by the physician. It is encoun- 
tered during the period of chill, and often takes place in pain- 
ful conditions of the pleura and thorax wall ; this has been 
termed jerking respiration. Its diagnostic importance consists 
in the fact that it occurs in catarrhal conditions of the finer 
bronchi, especially at the apices of the lung, and is an early 
sign of the infiltration of tubercles (" cog-wheel respiration "). 
This sign is especially important if it should take place at both 
apices. Jerking inspiration occasionally occurs in severe 
bronchitis. It is often accompanied by prolonged expira- 
tion. 

Vesicular Breathing with Prolonged Expiration. — In 
healthy persons inspiration is, as a rule, four times as long as 
the indistinct expiratory murmur. However, should inflam- 
matory exudates appear in the bronchial tubes, the expiratory 
murmur sometimes equals, and occasionally is longer than, 
the inspiratory murmur. Should this sign be localized to the 
apices, it is indicative of incipient tubercular disease. Prolonged 
expiration further occurs in bronchial asthma and in chronic 
pulmonary emphysema, as in both these diseases expiration is 
of itself prolonged. 

Bronchial Breathing. — This type of respiration is heard 
normally in listening over the trachea and occasionally in the 
intrascapular spaces ; for this reason it is sometimes called 
laryngeal or tracheal breathing. It is well for the student to 
familiarize himself with this sound by placing the stethoscope 
over the trachea. It will be noted that the expiratory mur- 
mur is decidedly stronger than the inspiratory. It is of higher 
pitch and has a blowing quality, being especially marked in 
expiration. When this particular variety of breathing is heard 



EXAMINATION OF THE RESPIRATORY ORGANS. J I 

over any other portion of the lung, it indicates some patho- 
logic process. Bronchial breathing is encountered over airless 
spaces in the lung tissue and over cavities. It occurs over 
airless lung tissue because only tissues containing air have 
the property to change the bronchial sound as it passes 
through the trachea and bronchi into the vesicular murmur. 
If, then, the parts of the vesicular structure of the lung be- 
come impervious to air through consolidation from any cause, 
the property of changing the bronchial murmur of the larynx 
to the vesicular murmur disappears, and the bronchial respi- 
ratory sound is heard in the affected area. The production 
of bronchial breathing in cavities is due to other causes. 
Should a bronchus terminate in a cavity with firm walls, the 
transmitted sound from the trachea enters directly, producing 
columns of vibrations that are heard in the cavity as bronchial 
breathing. This may occur both in inspiration and in expiration. 
In this case the bronchial respiratory sounds are produced in 
the cavities themselves. In the bronchial breathing over the 
cavity it may be noted that the sound is more intense than 
the bronchial murmur produced over the trachea, and it occa- 
sionally differs in that it may be louder in inspiration than in 
expiration. This has also been called cavernous breathing. 
Two things are necessary for the appreciation of bronchial 
breathing — (i) that the affected area must be superficially 
situated, and (2) that the bronchial tubes that lead to the dis- 
eased part must be free to the egress of air ; thus it may 
occur in consolidated portions of lung, as in croupous pneu- 
monia. The bronchus that leads to the pneumonic area may 
be plugged by mucus or other secretion, and bronchial or 
other forms of respiration will be entirely absent. The same 
condition takes place if a pleural exudate should be present 
in the affected area. Bronchial breathing is more easily 
appreciated by the ear than is the normal vesicular murmur, 
as the sound more closely resembles a musical note, being 
decidedly higher in pitch than the normal vesicular murmur. 
The pitch of bronchial breathing occurring in the trachea is 
higher in inspiration than in expiration, being also changed 
by opening and closing the mouth. It is higher in children 
and in women than it is in men. Over cavities the pitch of 
the bronchial murmur will depend upon the fact that the 
smaller the diameter of the cavity and the larger the opening 
into the bronchus, the higher the pitch of the respiratory 
sound will be. Occasionally, there may be a mixture of the 



7 '2 PHYSICAL DIAGNOSIS. 

bronchial and vesicular types. This is known as broncho- 
vesicular respiration, and shows the quality of both the bron- 
chial and vesicular types. One or the other of the types may 
predominate. It is also known as harsli respiration. The 
more pronounced the bronchial element, the higher the pitch 
and the more prolonged the expiration. The important ele- 
ment in the recognition of this form of respiration consists in 
the mixture of the vesicular and the tubular quality during 
inspiration. It is suggestive, and denotes incomplete consoli- 
dation. The more pronounced the solidification, the greater 
the bronchial element, and the nearer the affected area is to 
the surface, the greater the bronchial type of respiration. 
This form of breathing is heard during the stage of resolution 
in croupous pneumonia. It is a valuable sign in incipient 
pulmonary tuberculosis, in interstitial pneumonia, in hemor- 
rhagic infarct, and in compression of the lung from tumors, 
fluid, or air. It must be borne in mind that occasionally the 
respiratory murmur over the right apex is less vesicular and 
higher in pitch than over the left — in other words, the right 
apex normally shows a mild type of harsh respiration or 
bronchovesicular breathing. Sometimes bronchial breathing 
has a metallic or even a musical tone, or may have the char- 
acter of an echo. This may be imitated by breathing into a 
bottle or decanter, and has been termed amplwric breathing. 
It shows that air has entered into a cavity and that it has not 
been expelled with expiration. Amphoric respiration may be 
heard with inspiration, with expiration, or with both. When 
it occurs in but one respiratory act, it is more frequently heard 
in expiration alone, being louder and more distinct. This 
sound is present only in large pulmonary cavities and in pneu- 
mothorax. Amphoric respiration occurs in a pulmonary 
cavity with rigid walls. The cavity must be sufficiently large 
for a free communication with a fair-sized bronchial tube, and 
be situated close to the surface of the lung. Cavernous respi- 
ration has already been partly described in a previous section, 
under bronchial breathing. (See p. 71.) The term cavernous 
respiration is not accepted by the Germans. Simply defined, it 
is a variety of bronchial breathing. It has the character of respi- 
ration heard over a cavity. The inspiration is blowing, and 
the pitch somewhat lower than that in bronchial breathing. 
Expiration and inspiration have almost the same quality, 
duration and intensity being variable. Bronchocavernous respi- 
ration is a rare physical sign, as is also vesiculocavernous 



EXAMINATION OF THE RESPIRATORY ORGANS. 7 '3 

respiration. The latter occurs where the cavity is surrounded 
by apparently healthy tissue. 

Rales. — Rales are adventitious new sounds, occurring 
during the act of respiration, created in the bronchi, lungs, or 
pleura. When heard in the lungs or bronchi, they are termed 
rales ; and when heard in the pleura, they are known as fric- 
tion sounds. Broadly speaking, they are divided into two 
classes — dry and moist rales. 

Dry Rales. — Dry rales are appreciated as piping or whis- 
pering and snoring or humming, being either high pitched or 
low pitched. The former are termed sibilant rales ; and the 
latter, sonorous rales. They are produced by a diminution in 
the lumen of the bronchial tube, either through the deposit of 
a tough tenacious exudate, due to inflammation, or from pres- 
sure upon the tube by tumors, gas, or fluid. Sonorous rales 
are produced in the large, and sibilant rales in the small, 
bronchial tubes. They are heard both in inspiration and in 
expiration. Should they appear only in one of these two 
conditions, they are most likely to be heard in inspiration 
alone. The sonorous rales may be mistaken for pleural fric- 
tion, but the differential diagnosis between the two conditions 
is not difficult, as the friction sound is limited in extent, 
whereas the sonorous rale is heard over a large area. These 
rales occur commonly in the first stage of acute bronchitis, in 
asthma, and in chronic bronchitis. Coughing may either in- 
crease or diminish the rale. 

Moist Rales. — Moist rales are divided into large and into 
small mucous rales, into crepitant and into subcrepitant rales. 
Large moist rales are produced in the larger bronchial tubes 
and in cavities. They are caused by the passage of air 
through secretion, the current of air throwing the fluid into 
vibration in the act of respiration. Talma has given another 
explanation : " When we blow through a tube one end of 
which is immersed in water, it is supposed that the current of 
air separately moves the air-bubbles which present projections 
into the bronchial tubes, and that as one such quantity of air 
breaks the bridge through the fluid and advances, the fluid 
behind it immediately rushes on again and occupies the space 
and shares the vibrations in the pent-up air." Traube 
thought that the to-and-fro motion of the secretion produced 
by the current of air caused moist rales. The explanation 
most generally accepted to-day is the following : If air enters 
a bronchial tube in which secretion is present, the inspired 



74 PHYSICAL DIAGNOSIS. 

column of air forces the fluid down. through the tube so that 
at some level it causes the formation of a diaphragm, this 
is pushed further and further through the tube until the 
lumen of the vessel becomes too narrow to hold it, when it 
breaks, producing a sound (the rale) ; the reverse takes 
place in expiration : the diaphragm is again formed at the 
narrowest part of the tube, forced upward through the bron- 
chus until the lumen of the tube is too wide to hold the 
fluid diaphragm, when it again bursts, and produces a sound 
recognized as a rale. This explains why moist rales are heard 
both in inspiration and expiration, with the single exception 
of the crepitant rale, which has another mechanism that will 
be considered later on. The small mucous rale is produced 
in the same way as the large mucous rale. The larger and 
medium-sized moist rales are heard in the second stage of 
bronchitis, in the stage of asthma in which expectoration ap- 
pears, in the second stage of acute bronchitis when fluid 
begins to form, and, in fact, in any condition in which fluid 
is present in the larger or medium-sized bronchial tubes. 
They are also heard over a cavity when fluid is present, and 
produce a sound of a gurgling character ; hence, they are 
called gurgling rales. Occasionally, rales are heard which 
have a decided metallic quality. They occur over superfi- 
cially situated cavities with smooth walls. This has been 
called metallic tinkling, and sometimes resembles the sound of 
falling drops. This rale is heard particularly in hydro- 
pneumothorax, and has also been called gntta cadens. Baas 
called attention to the fact that if fluid form at the top 
of a cavity, the drop does not fall directly to the lowest level, 
but gravitates along the walls ; thus, the name gutta cadens, 
which was given to it by Laennec, describes the sound more 
than the actual condition. 

Tlie Saber epitant Rale. — The subcrepitant rale is formed in 
the small bronchioles. It is heard in inspiration, in expira- 
tion, or in both. The element of moisture is pronounced, 
and gives the rale known as crackling. In occurs in con- 
gestion and edema of the lungs, in hemorrhage, or in any 
condition in which fluid is present in the finer air-passages ; 
hence, the rales are occasionally present in the early stages 
of chronic pulmonary tuberculosis, and in the stage of reso- 
lution of croupous pneumonia. 

The Crepitant Rale {Crepitation). — This rale has a peculiar 
acoustic property, which may be imitated by rubbing the hair 



EXAMINATION OF THE RESPIRATORY ORGANS. 75 

in front of the ear between the fingers. It is produced only 
in the alveolar structure of the lung, and is heard only at the 
end of a forced inspiration. It is due to the alveolar structure 
being collapsed and glued together, or when the alveoli are par- 
tially filled with secretion. Thus, it may occur in persons who 
have been bed-ridden in whom atelectasis of the lungs at the 
bases has appeared. After a prolonged inspiration, the alveoli 
separate as the air enters, and the rale is heard at the end of 
inspiration. It most commonly occurs pathologically from 
accumulation of fluid in the alveoli and parts of the fine 
bronchi. The rale appears commonly in croupous pneumonia, 
bronchopneumonia, hemorrhage, pulmonary infarcts, edema 
of the lung, and occasionally in pulmonary tuberculosis. Pen- 
zoldt has called attention to the fact that sometimes crackling 
or crepitation may be heard in expiration. This view has 
not received general acceptance. 

Pleuritic Friction Sounds. — These are heard when the 
pleural surfaces are roughened, the intensity varying from the 
slightest rubbing to a shuffling or creaking sound, which may 
not only be heard, but may be readily transmitted to the 
hand through palpation. The sound may be heard either in 
inspiration, in expiration, or in both. It is close to the ear, 
superficial, and is increased by pressure with the stethoscope, 
which causes pain. The pronounced loud sound may be 
broken or interrupted during respiration. The low, less intense 
sounds are usually continuous. The sound disappears with 
the formation of fluid in the pleural cavity. It reappears as 
absorption takes place. Pleuritic friction is usually localized 
(circumscribed). Occasionally, a friction sound is heard that 
is synchronous with the heart-beat. This is known as pleuro- 
pericardial friction, and will be described under Pericardial 
Friction Sound. (See p. 91.) If the pleural friction sound 
occur in inspiration, it may be mistaken for the crepitant rale. 
The points of difference are these : The crepitant rale is usu- 
ally not so circumscribed, being heard over a wider area ; it 
accompanies consolidation, and is not influenced by cough, 
pain not being a prominent symptom. 

Auscultation of the Voice (Vocal Resonance). — For diag- 
nostic purposes the ear may be placed upon the chest (imme- 
diate auscultation), or the stethoscope may be used (mediate 
auscultation), and the patient asked to speak with the loud 
and with the whispered voice. If the stethoscope is placed over 
the larynx during the act of speaking, a loud, almost disa- 



j6 PHYSICAL DIAGNOSIS. 

greeable, sound is transmitted to the ear. The voice is carried 
from the trachea into the bronchial tree. The vocal reso- 
nance will be greater under normal conditions, depending upon 
the size and the superficial situation of the bronchi. The de- 
velopment of the chest also influences the vocal resonance ; 
thus, the more developed the chest and the greater the thick- 
ness of the muscular Avails, the less pronounced the vocal 
resonance appears. Vocal resonance is less marked in 
children and in women than in men, and is more distinct 
in the aged than in middle life. In general terms it may 
be stated that vocal resonance and vocal fremitus are influ- 
enced by the same conditions. A possible exception may 
take place in the accumulation of fluids in the pleural cavity. 
Occasionally, although rarely, large pleural effusions may 
exist over which the voice will be transmitted to the ear. An 
increase of vocal fremitus is noted in all conditions of consoli- 
dation ; hence it occurs in pneumonia and tubercular disease 
of the lungs. When the vocal resonance over the chest 
assumes the character that it has over the trachea, it is spoken 
of as bronchophony. This sometimes occurs over cavities, and 
becomes especially plain when the whispered voice is used, 
being then known as whispering- pectoriloquy. Occasionally, a 
nasal bleating sound is heard, especially over pleuritic exu- 
dates. This condition is called egophony. It is supposed to 
resemble the bleating of a goat ; hence the name. 

The Bacelli Sign. — Bacelli has described a sign to deter- 
mine the nature of pleural exudates. According to Bacelli, 
the whispered voice will be heard through serous effusions, 
but not through purulent effusions. The sign is not reliable, 
and clinically very little importance should be attached to it. 

The amphoric voice may be associated with amphoric res- 
piration. It may occur either with a loud voice or a whisper ; 
it is usually, however, more marked with the latter. 

Bell Tympany. — This occurs when air is confined in the 
pleura. If the ear is placed over the chest anteriorly and 
two coins are tapped one against the other, at the opposite 
side of the chest, a distinct, metallic, ringing sound is trans- 
mitted to the ear. It occurs particularly in pneumothorax, 
never occurring over normal lung. 

Succussion. — The succussion sound was first described by 
Hippocrates ; hence it is termed Hippocratic succussion. It 
occurs only in conditions in which fluid and air are present in 
the pleural cavity. It is elicited by placing the ear upon the 



PHYSICAL DIAGNOSIS OF THE HEART. J J 

chest and shaking the patient vigorously, when a splashing 
sound is transmitted to the ear. This sound is often appar- 
ent to the patient, and is observed with a change in position. 
The sound is exactly similar to that produced by shaking a 
large vessel partially filled by fluid. It takes place particularly 
in hydropneumothorax, and occasionally may be heard over 
the stomach when that organ contains gas and fluid. 



PHYSICAL DIAGNOSIS OF THE HEART. 

The methods of physical diagnosis employed in the exami- 
nation of the heart consist in inspection, palpation, percussion, 
and auscultation. 

Inspection of the Heart. — Inspection of the heart should 
be undertaken in a good light, preferably with the patient in 
the sitting or dorsal position. Daylight is the best for this 
purpose. The following points should be noted, and are of 
importance : The apex-beat, its diffusibility , and any abnormal 
pulsation in the cardiac area. The heart is inclosed in the 
pericardial sac and is placed obliquely in the chest. " The 
broad attached end or base is directed upward and backward 
to the right, and corresponds to the interval between the fifth 
and eighth dorsal vertebrae. The apex is directed forward and 
to the left, and corresponds to the interspace between the car- 
tilages of the fifth and sixth ribs in the parasternal line. The 
heart is placed behind the lower two-thirds of the sternum, 
and projects further into the left than into the right cavity of 
the chest, extending from the median line about three inches 
in the former direction, and only one and one-half inches in 
the latter. Its upper border would correspond to a line drawn 
across the sternum on a level with the upper border of the 
third costal cartilages, and its lower border to a line drawn 
across the lower end of the gladiolus from the costoxiphoid 
articulation of the right side to the point previously mentioned 
as the situation of the apex. The lungs cover a large part of 
the heart, and during inspiration when their borders meet 
behind the sternum a thin layer of lung covers the roots of 
all the large vessels ; hence, the custom of making the patient 
hold the breath while examining the sounds of the heart" 
(Gray). 

The Apex=beat of the Heart. — If the chest of a healthy indi- 
vidual is examined, it will be noted that in the fifth left inter- 
costal space, at or near the parasternal line, there is a circum- 



7 8 PHYSICAL DIAGNOSIS. 

scribed rhythmic bulging, which is known as the apex-beat of 
the heart. It occurs with the systole or first sound of the heart, 
and is almost coincident with the pulse of the carotid and 
radial arteries ; more correctly stated, it is perhaps slightly in 
advance — 0.0093 of a second before the carotid artery and 
0.0224 of a second before the radial artery. The breadth of the 
apex is about 2. 5 cm., showing that it can be easily covered with 
the tip of one finger. In early childhood the apex-beat is often 
situated higher : in the fourth year it is most often found in the 
fourth intercostal space. The apex-beat of the heart is not 
visible in all persons. In some few individuals it is often not 
perceptible to the eye ; occasionally, in women who have a 
short thorax and small intercostal spaces, the apex-beat may 
not be noted. In all such cases palpation must be resorted to. 
The thinner the chest-wall, the plainer the apex -beat ; hence, 
it is usually noted to a greater extent in children than in adults. 
Several points are of importance in consideration of the apex- 
beat : the position, the breadth, the strength, the time, and the 
rhythm. 

Position of the Apex=beat. — As has already been indi- 
cated, the apex-beat in children is situated somewhat higher 
than in adults, whereas in the aged in may be as low as the 
sixth intercostal space. In deep inspiration the apex-beat 
may be displaced downward one or more intercostal spaces, 
returning, however, to its normal place with deep expiration. 
It is more apparent in expiration, approaching nearer the 
mammillary line at this time. On the other hand, it may 
partly or completely disappear on inspiration, as the overlap- 
ping left lung may entirely cover it. The position of the apex- 
beat changes with posture. It falls from three to six centi- 
meters to the left, and from one and a half to three centimeters 
to the right, accordingly as the body lies upon the left or upon 
the right side. Slight retraction also takes place if the sitting 
or upright posture is exchanged for the horizontal. Bodily 
exercise and mental emotion have some influence upon the 
apex -beat. It may become stronger, broader, and change 
its position a little more to the left and downward under these 
influences. Congenital deformities have some effect upon 
the position of the apex-beat of the heart ; thus, in dextro- 
cardia the heart is found upon the right side, in the same 
position that it should normally assume upon the left side. 
It will also be found that other organs have changed their 
position ; thus, the liver will be found upon the left side, the 



PHYSICAL DIAGNOSIS OF THE HEART. 79 

spleen upon the right, the cardiac end of the stomach upon 
the right side, and the pylorus upon the left side, etc. Other 
malformations have been described in the chapter upon 
Diseases of the Heart. (See p. 313.) Alterations in the con- 
tour of the heart produce changes in the position of the apex. 
Among the diseases of the lungs chronic pulmonary emphy- 
sema and interstitial disease produce dislocations of the apex- 
beat. In pulmonary emphysema the volume of the lung is 
increased so that the diaphragm, and with it the heart, are 
pushed down lower than their normal positions. In intersti- 
tial pneumonia the heart, on the contrary, is drawn in the 
opposite direction. Great changes take place in the position 
of the apex-beat from disease of the pleura. Accumulations 
of gas or fluid in the pleural cavity push the apex-beat to 
the opposite side. In diseases of the right pleura the apex- 
beat may even be found in the left axillary line, whereas in 
left-sided disease the change is not apt to be so great. Fried- 
reich has called attention to the fact that in right-sided pleural 
effusion the apex-beat is also pushed forward. It not infre- 
quently happens that from disease of the pleura the apex -beat 
may permanently assume the position that it first received in 
its dislocation. Diseases of the mediastinum, such as en- 
larged lymphatic glands, displace the apex-beat downward 
and outward. Diseases of the abdominal organs, tumors, 
and accumulations of gas or- fluid in the peritoneum cause a 
dislocation of the apex-beat upward and outward. Gerhardt 
has called attention to the fact that dislocation of the apex- 
beat does not occur in pregnancy. Further, it must be men- 
tioned that the apex-beat may be displaced from disease of 
the circulatory apparatus itself : thus, a downward displace- 
ment occurs from aneurysm of the aorta ; a downward dis- 
placement is not infrequently noted from accumulation of fluid 
in the pericardium. Finally, diseases of the heart-muscle 
produce marked changes in the position of the apex-beat ; 
thus, from disease of the left ventricle the apex-beat is often 
displaced downward to the left, showing hypertrophy. 

Breadth of the Apex=beat. — The breadth of the apex-beat 
varies considerably even under normal circumstances. Exer- 
cise and emotion may cause an increase in the breadth of the 
apex-beat. It also becomes broader in expiration in the up- 
right position and in a forward leaning of the bod}', so that 
the heart approaches nearer the thorax wall. Pathologic con- 
ditions show an increase in the breadth of the impulse in all 



80 PHYSICAL DIAGNOSIS. 

cases in which the heart comes nearer the thorax, especially 
if associated with retraction of the left anterior border of the 
lung. It results particularly from increase in substance of 
the left ventricle. 

Force of the Apex=beat — This is estimated by the degree 
of resistance which the heart offers to the finger when placed 
over the position of the impulse. A strong impulse is called 
heaving and resistant. To appreciate these differences, the 
student must be familiar with the force of the normal apex- 
beat. A powerful, heaving, resistant apex-beat is a sign of 
hypertrophy of the left ventricle. As a rule, all conditions 
that produce a slowing of the cardiac action are combined 
with increased force of the apex-beat. Occasionally, this may 
be due to febrile conditions, and in those cases of palpitation 
from which nervous and hysteric persons are apt to suffer. 
An enfeebled impulse is due to the loss of power in the heart 
muscle, and is an important sign in myocardial disease. A 
weak or absent impulse may be due to a portion of lung in- 
tervening between the heart and the thorax, and is very likely 
to occur in chronic pulmonary emphysema. A like condi- 
tion is apt to take place from an accumulation of fluid in the 
pericardial sac. Under normal circumstances in deep inspira- 
tion the impulse becomes weaker for the reason that the left 
lung at that time will be found to cover a larger part of the 
cardiac area. In pathologic conditions this fact is of import- 
ance. Thus, it occasionally occurs from extrapericardial 
adhesions that the impulse may become more powerful and 
apparent during full inspiration. The impulse may be weak- 
ened or entirely absent from adhesion of the two layers of the 
pericardium. Finally, changes in the wall of the thorax itself 
may produce a weakened or absent impulse, such as edema 
of the chest-wall, inflammatory conditions, and a large accu- 
mulation of fat. 

Systolic Retraction. — Systolic retraction is encountered in 
the region of the apex-beat, in which several interspaces of 
the thorax wall are drawn in with every systole of the ventri- 
cle. With diastole the retracted parts again come forward 
and almost give the appearance of a diastolic apex-beat. The 
retraction is usually more apparent in inspiration than in ex- 
piration. This sign is noted in adhesive pericarditis, especi- 
ally in the form known as mediastinal pericarditis. The sign 
is also known as systolic dimpling. Simpson has called atten- 
tion to the fact that the retraction only occurs at the latter 



PHYSICAL DIAGNOSIS OF THE HEART. 8 1 

part of the systole, as may be observed by keeping the finger 
over the carotid or radial arteries. 

Rhythm of the Apex=beat. — As a rule, the apex-beat is 
felt as a systolic impulse ; occasionally, however, a double 
impulse is felt. This doubling of the impulse, according to 
Leyden, is due to a separate contraction of the right and left 
ventricles. These contractions of the ventricles occur inde- 
pendently of each other, so that there is practically a hemi- 
systole. This condition has been called a reduplicated first 
sound. The production of the apex-beat of the heart is by no 
means settled ; several theories have been advanced as to its 
production : Bamberger thought that it concerned the apex 
of the heart alone ; the theory generally accepted is that the 
heart-beat occurs about in the middle of the time between the 
closing of the auriculoventricular and arterial valves, that it 
takes place in the first part of the systole, which has been 
called the time of closing (Verschlusszeit). This is the time 
at which the ventricle is filled with blood, and in which all 
valves are still closed. It is then due to the change in the 
form of the heart muscle. These observations were made by 
Martin by means of the cardiograph ; they are, however, by 
no means generally accepted. 

Diffused Impulse. — As has already been suggested, nor- 
mally the impulse of the heart is limited to the fifth intercostal 
space upon the left side in the parasternal line. Should the 
impulse be seen over a larger area, it is spoken of as a diff'used 
impulse. This results very often from dilatation of the right 
ventricle, and may be seen to the right of the left sternal line 
and even in the epigastric region. If hypertrophy should 
coexist, the impulse becomes more powerful. 

Prominence or bulging in the cardiac area, which may in- 
clude both the sternum and the ribs, may take place from 
hypertrophy and from dilatation. Pericarditis with effusion 
also gives rise to distinct bulging. Pulsations are sometimes 
localized, — they may be limited to the base of the heart in the 
second intercostal space on the right and left sides, — and may 
be due either to the aorta or the pulmonary artery. If these 
pulsations are systolic in time, they are likely to indicate 
aneurysm of these vessels. From what has been said under 
inspection it will be noted that the lowest tip of the heart, the 
actual apex (anatomic apex), rarely comes against the chest- 
wall, that the systole of the heart that can be seen and felt is 
due to the right ventricle, so that, clinically at least, the right 
6 



82 PHYSICAL DIAGNOSIS. 

ventricle is the apex of the heart, whereas the left ventricle 
forms the anatomic apex. 

Palpation of the Heart. — Palpable Apex=beat. — The apex- 
beat is felt as a short, sharp shock, which is systolic in time. 
It has no particular diagnostic, significance. Frequently, a 
diastolic shock of moderate intensity may be discerned at the 
base of the heart, which is also normal. The diastolic shock 
(which is normal) is found to be diffused ; it assumes diag- 
nostic importance when it becomes localized. This occurs 
most often in the second left intercostal space close to the 
sternum, in the region of the semilunar valves of the pulmonary 
artery. The reason for this may be due to favorable circu- 
latory conditions or to increased force of the pulmonary valves. 
Favorable circulatory phenomena occur when the border of 
the left lung that covers the pulmonary artery has become 
infiltrated and airless or is retracted so that the pulmonary 
artery lies closer to the chest-wall. Under such circumstances, 
visible pulsation over the pulmonary artery may be noted. 
Increased force of the pulmonary valves takes place when 
difficulty or great resistance is encountered in the right ven- 
tricle. This occurs most frequently from disease of the mitral 
valve and in chronic pulmonary affections. In the two right 
intercostal spaces near the sternal border the diastolic shock 
is rarely encountered. It occasionally results from hyper- 
trophy of the left ventricle, due to contracted kidney. 

Palpable Murmur. — Pathologic changes in the heart fre- 
quently give rise to adventitious sounds. These are par- 
ticularly noted upon auscultation, but may sometimes be 
discernible by palpation. Depending upon the position in 
which they arise and their character they are known as endo- 
cardial or pericardial sounds. Ordinarily, pericardial and 
endocardial sounds can be differentiated by the sensations 
which they impart to the finger. Pericardial murmurs are 
known as friction sounds. They give the hand the sensation 
of rubbing, scratching, or shoving, and are characterized by 
marked interruptions, whereas endocardial sounds that are 
apparent to the finger have a more continuous character, much 
like the purring of a cat or the sound of a violin string which is 
thrown into vibrations. The differential diagnosis is rendered 
easier if the sound is only discernible upon strong pressure in 
one interspace. This would favor the fact that the sound was 
of pericardial origin, being produced through the closer prox- 
imity of the pericardial layers upon pressure. It is also 



PHYSICAL DIAGNOSIS OF THE HEART. 83 

important to notice the time at which these phenomena 
occur. 

Endocardial sounds have a definite relation to the phases 
of the action of the heart, and are systolic, diastolic, or pre- 
systolic in time. Pericardial friction sounds differ markedly 
from this : they are neither strictly systolic nor diastolic, but 
may occur independently of systole or diastole, and are not 
definitely related to either the first or second sound. If there 
should be still further doubt, auscultation should be resorted 
to. Both murmur and friction rub may disappear in deep 
inspiration to the palpating finger. According to the sensa- 
tions that the endocardial murmur give to the finger, they are 
known as purring and fremissement cataire (Laennec). The 
sound is also described as a thrill. On the other hand, the 
palpable pericardial friction sounds are spoken of as friction 
rubs, usually giving rise to a loud sound to~ the ear. They 
may partially disappear when the heart is acting quietly, but 
are always increased by exercise or mental emotion, or by a 
change from the dorsal decubitus to the upright posture. 
The thrill is of great importance in the diagnosis of valvular 
disease of the heart. When present, it is a most important 
sign of stenosis of the valve according to the position in 
which it occurs. A thrill at the apex, presystolic in time, is 
significant of mitral stenosis. A thrill in the second right 
intercostal space, systolic in time, is diagnostic of aortic steno- 
sis. Thrills occurring in relation to the right heart are ex- 
ceedingly rare, but a thrill in the region of the tricuspid valve, 
presystolic in time, would point to tricuspid stenosis, and a 
thrill in the second or third interspace upon the left side at 
the base would be suspicious of stenosis of the pulmonary 
valves. The presystolic thrills are further characterized in 
that they are usually more marked at the beginning and end 
of the thrill than during its middle course. Palpable pericardial 
friction sounds only occur when inflammatory changes take 
place in the pericardium. Pericardial friction sounds are most 
frequently felt in the neighborhood of the left sternal border. 

A rare sign elicited upon palpation occurs over the trachea 
in some cases of aortic aneurysm. The observer should 
stand behind the patient, and his fingers should firmly grasp 
the cricoid cartilage. The patient should rest the chin upon 
the chest, and he should be told to hold the breath. An 
upward and downward motion of the trachea is noted if the 
sign is present. It is known as tracheal tugging. 



84 PHYSICAL DIAGNOSIS. 

Percussion of the Heart. — Percussion of the heart should 
be practised by using the fingers. The patient should be in the 
recumbent posture or slightly elevated, assuming a partial sit- 
ting position. But a small portion of the heart is uncovered by 
lung. This extends from the fourth to the sixth costal carti- 
lages. The area of superficial dullness does not extend more 
than two inches in any direction. It has a triangular shape, 
the apex being below the juncture of the third left rib with 
the sternum, and the base being on a line with the cartilage 
of the sixth rib. Normally, the area of deep-seated dullness 
extends from the left nipple to about one-half of an inch to 
the right of the sternum transversely, and from the second 
to the sixth interspaces vertically. The lower border of the 
heart belongs to the right ventricle ; the left border consists 
of the left ventricle, beginning about at the middle of the 
second left intercostal space and extending downward to the 
fifth left intercostal space. Percussion of the heart, as will be 
noted from the description, is exceedingly difficult, and can 
only be practised with some degree of accuracy in cases in 
which pericardial effusions take place. Recognizable changes 
upon percussion of the heart occur if gas or fluid is present in 
the pericardial sac. In the case of gas a tympanitic note is 
found where cardiac dullness should be encountered ; if there 
be fluid, great changes take place in the pericardium. Con- 
siderable increase in the size of cardiac dullness and absolute 
flatness upon percussion are noted. In very large effusions 
the greatest area of flatness is noted at the apex of the heart, 
merging into dullness as the normal base of the heart is 
reached. The shape of the flatness is described as being tri- 
angular, with the base of the triangle toward the apex of the 
heart. 

Auscultation of the Heart. — Auscultation of the heart 
should be practised by means of the stethoscope, each valve 
position being carefully auscultated. It is apparent to any one 
familiar with the anatomy of the heart that the area of a silver 
dollar pressed upon the heart would come in contact with each 
of the four valves ; hence, it has been necessary to study care- 
fully the points at which the valve sounds could be individu- 
ally determined. The point of maximum intensity at which the 
valve sound can be heard is called the punctum maximum. 
Anatomically, the position of the mitral valve is about at the 
third left costal cartilage, near the sternum. The position 
at which it should be auscultated is at the apex of the heart. 



PHYSICAL DIAGNOSIS OF THE HEART. 85 

The situation of the tricuspid valve anatomically is in a line 
drawn between the third left intercostal space and the fifth 
right costal cartilage. The punctum maximum is in the me- 
dian line at about the fifth right costal cartilage. The anatomic 
location of the aortic valve is between the median line and the 
third left costal cartilage. The punctum maximum is the 
second right costal cartilage, sometimes called the aortic carti- 
lage. The anatomic position of the pulmonary valve is in the 
middle of the second left costal cartilage, 1.5 cm. to the left 
of the sternal border. The punctum maximum is between 




Fig. 7. — The anatomic situation and the points for auscultating the valves of the 
heart and its orifices. The crosses indicate the anatomic situation ; the black points and 
lines indicate the places to auscultate. The small letters show the location of the valves ; 
the large ones, the points for auscultating : a A, The aorta ; m M, mitral valve ; p P, the 
pulmonary orifice ; t T, tricuspid (Vierordt). 

the second and third left intercostal spaces, near the left sternal 
border. In auscultation it is necessary to differentiate between 
the sounds of the heart and murmurs that may be present, 
and a further distinction must be made between endocardial 
and exocardial murmurs. The exocardial murmurs occur in 
disease of the pericardium, and are identical with friction 
sounds. 

Auscultation of the Heart=sounds. — If the ear is placed 
over the cardiac area in a normal individual, two distinct 
sounds are encountered — one is called the systole or first 
sound, the other the diastole or second sound. They are 



86 PHYSICAL DIAGNOSIS. 

separated from each other by a short pause, whereas a longer 
pause occurs between the second and first sounds. The first 
sound is due to the contraction of the ventricle, producing the 
muscular element, the rush of the blood, and the closure of 
the auriculoventricular valves ; the second sound is due to the 
closure of the semilunar valves in the aorta and pulmonary 
artery. The first sound is then synchronous with the apex- 
beat, and is the long sound ; the second is the short, sharp, 
valvular sound. The first sound is heard with greatest inten- 
sity at the apex of the heart ; the second sound is best studied 
at the base. 

Rhythm of the Heart=sounds. — The first sound is charac- 
terized by a dull, deep, more prolonged, and less sharply 
defined hum than the second higher pitched, snappy, valvular, 
diastolic sound. The strength of the cardiac sounds depends 
upon the thickness of the thorax. In a thin thorax the sounds 
are more pronounced than in a thick-walled chest. Edema 
of the chest-wall may show a decided influence upon the in- 
tensity of the heart-sounds. In deep inspiration the strength 
of the cardiac sounds diminishes, as is also the case in decided 
pulmonary emphysema. In consolidation of the lung, on the 
other hand, this acts as a favorable medium for the transmis- 
sion of heart-sounds, as do also cavities in the lung. In syn- 
cope the heart-sounds may be so feeble that they can not be 
heard. The same is true, especially of the first sound, in 
many of the infectious diseases, in fatty infiltration of the 
heart-muscle, and in many forms of myocarditis. The second 
sound of the heart is accentuated in all conditions in which 
an increase of the cardiac muscle takes place, especially 
in hypertrophy of the left ventricle. The same is true in 
arteriosclerosis and in contracted kidney. Accentuation of 
the second pulmonary sound is an important sign of hyper- 
trophy of the right ventricle. An accentuation of the sys- 
tolic sound takes place at the apex, as was first pointed out 
by Traube in mitral stenosis. The reason lies in the fact that 
from stenosis of the auriculoventricular opening of the left 
side of the heart the blood can only slowly enter the ventricle, 
so that as less blood is present in the ventricle the contrac- 
tion of the ventricle becomes more powerful, showing this by 
accentuation of the first sound. A diminution in the intensity 
of the first sound may occur from aortic insufficiency. It is due 
to the fact that at the end of diastole the mitral valve has already 
become tense, and so the increase of the tensity of the valve 



PHYSICAL DIAGNOSIS OF THE HEART. 87 

during systole, in final closure, is not well marked. Dimi- 
nution in the intensity of the second sound at the aorta and 
pulmonary arteiy may be due to diminished blood-pressure 
and from the reduction in the contractile power of the semi- 
lunar valves from thickening. The second sound may be en- 
tirely absent, especially the aortic, in mitral regurgitation 
and stenosis. In a high grade of stenosis of the mitral valve 
very little blood enters from the auricle into the ventricle, so that 
at the following systole a very small amount of blood is sent 
from the ventricle into the aorta, causing the aortic valves to 
close with but slight force, the second sound being weakened 
or entirely absent. The second aortic sound is often accentu- 
ated, and sometimes has a ringing quality. In arteriosclerosis 
a metallic sound is sometimes added, also if large cavities are 
situated in the lungs near the heart. This may result from 
tubercular disease of the lungs, pneumothorax, pneumoperi- 
cardium, and occasionally from meteorism. It has also been 
observed in adhesive pericarditis. 

Reduplication of the Heart=sounds. — Occasionally, there 
is a reduplication of the heart-sounds in which the rhythm of 
the heart is altered, depending upon whether the reduplication 
be systolic or diastolic. Should it occur with the systole, it is 
particularly noted at the apex or at the punctum maximum 
of the tricuspid valve. If it takes place with the diastole, it 
is most likely to be heard at the base, at either the pulmonary 
or aortic orifices. The cause of reduplication of heart-sounds 
is due to the failure of synchronous action of the valves or 
the ventricles. The condition occurs commonly in valvular 
disease from thickening or retraction of the valve segments, 
and in some cases of disturbance of innervation, as when the 
papillary muscles contract at different times. 

Under the name of gallop rhythm, a peculiar reduplication 
of heart-sounds has been described, in which the accentuation 
is laid upon the middle tone, so that the sound is not unlike 
the galloping of a horse. There is no satisfactory explanation 
of this condition. It has been found in emphysema with cir- 
culatory disturbance, in arteriosclerosis, and in cases of insuf- 
ficiency of the mitral valve. According to Fraentzel, the 
gallop rhythm points to grave cardiac weakness, and is an 
unfavorable prognostic sign. It is encountered in the severe 
infections, in the cachexia of malignant diseases, and in severe 
anemic conditions. Friedreich has called attention to the 
reduplication of the second sound occurring in pericarditis, in 



88 PHYSICAL DIAGNOSIS. 

which the layers of the pericardium have fused together, 
accompanying systolic contraction. 

Auscultation of Endocardial Murmurs. — We owe this im- 
portant physical sign almost entirely to the researches of 
Skoda, who called attention to the fact that in the auscultation 
of murmurs two things were of particular importance — the posi- 
tion in which the murmur occurred with the greatest intensity, 
and its time in the cardiac revolution. The situation in which 
the murmur is heard with greatest intensity almost invariably 
points to the orifice at which the diseased valves are situated, 
while the time at which the murmur occurs points to either 
regurgitation or stenosis, or both. The acoustic character of 
the individual murmur is without diagnostic importance. All 
degrees of variations of sounds are heard. The murmurs 
have been described as rasping, sawing, snoring, blowing, 
whistling, and so on. Occasionally, a high-pitched piping, or 
even singing, quality may be noted, when the term musical 
murmur has been used to signify the condition. In the vicin- 
ity of large cavities murmurs may even have a metallic qual- 
ity. The intensity of the murmur also shows great varia- 
bility. The question of muscular force of the heart very 
largely enters into this. If the heart be acting quietly, mur- 
murs may disappear entirely, and only reappear when the 
heart's action is most active — as a result of bodily exercise or 
mental emotion. In many cases posture is of great import- 
ance ; as a rule, in the erect posture endocardial murmurs are 
less intense or may disappear altogether ; rarely, the opposite 
of this may occur. The reasons for these phenomena are not 
clear, however, the lesson to be learned from them being that 
if valvular disease be suspected, the patient should be ex- 
amined in several postures. Occasionally, murmurs may be 
heard at some distance from the chest. As a rule, they are 
the murmurs of stenosis, particularly of the aortic valve. 
The rule that the position of the greatest intensity of the 
endocardial murmur shows the valve that is affected, may 
generally be adhered to ; there are, however, slight exceptions 
to this : for instance, the murmur of aortic insufficiency is 
often heard with greater intensity at the ensiform cartilage 
than at the second right cartilage, as the murmur does not 
have its origin in the beginning of the aorta, but in the left 
ventricle. Occasionally, the murmur of mitral regurgitation 
may be heard with greater intensity at the pulmonary area 
than at the apex of the heart. In reference to the time that 



PHYSICAL DIAGNOSIS OF THE HEART. 89 

endocardial murmurs arise they are divided into systolic and 
diastolic murmurs ; however, there is a murmur that occurs 
just before systole, known as the presystolic murmur, which 
is of great importance in the diagnosis of mitral stenosis. 
We then may divide organic murmurs into systolic, presystolic, 
and diastolic murmurs. Endocardial murmurs are divided 
into organic and functional murmurs. Organic murmurs are 
due to some anatomic alteration of the heart-muscle or of 
the valves. The functional murmurs occur in febrile condi- 
tions and in anemic affections, or diseases in which profound 
alterations of the blood take place ; hence, they are known as 
hemic, functional, and inorganic blood murmurs. The organic 
murmur is produced by fluid veins occurring in the blood 
stream. Physically, these fluid veins must occur in all cases 
in which the blood is forced suddenly to enter from a narrow 
opening into a wide one, or where two blood streams coming 
from opposite directions meet. This is known as the " Chau- 
veau's fluid vein theory." It accounts for the production of 
the organic murmur, but not for the functional murmur. No 
causes have been given that will satisfactorily explain the pro- 
duction of the functional or hemic murmur. 

Stenosis of the Aortic Orifice. — With the contraction of the 
ventricle, under normal conditions, the aortic valves should be 
open. If narrowing occurs, with the contraction of the ven- 
tricle, a systolic murmur is produced at the aortic cartilage 
due to the blood stream being impeded by the narrowed valve. 
This murmur often shows great intensity, and not infrequently 
has a musical character. This systolic murmur is transmitted 
to the vessels of the neck (carotid artery). 

In aortic regurgitation a diastolic murmur is produced at 
the aortic cartilage, due to the insufficient closure of the semi- 
lunar valve, allowing the blood to regurgitate into the left 
ventricle. This murmur is often heard with greater intensity 
at the ensiform cartilage than at the aortic cartilage. 

Mitral stenosis shows itself by a presystolic murmur, which 
is heard with greatest intensity at or near the apex. With 
the diastole of the heart the blood is forced from the left 
auricle through the narrowed mitral valve, so that the murmur 
must take place before the contraction of the ventricle, which 
is the systole. This murmur is not transmitted and is accom- 
panied by a presystolic thrill. 

Mitral regurgitation is diagnosticated by the presence of a 
systolic murmur at the apex, as with the contraction of the 



gO PHYSICAL DIAGNOSIS. 

ventricle blood is forced through the mitral valve back into 
the left auricle on account of the insufficient closure of the 
mitral valve. This murmur is transmitted into the axilla and 
to the angle of the scapula. 

Diseases of the right heart are extremely rare ; when they 
take place, the pulmonary valve lesions show similar murmurs 
to the aortic. The tricuspid lesions and the mitral lesions show 
the same murmurs. It must furthermore be added that the 
valve lesions characterized by stenosis almost always are ac- 
companied by a thrill that has the same rhythm as the murmur. 
Functional murmurs are always systolic in time. They are 
heard most frequently at the bases of the heart, particularly 
at the left base. They are not transmitted. Occasionally, the 
sound is heard in the veins of the neck, known as the venous 
hum. 

The differential diagnosis between the organic and functional 
murmurs is, as a rule, not difficult. 

Organic Murmur. ^^^rmur^ 1 

rp. f The time may be systolic, Always systolic in time. 
\ diastolic, or presystolic. 

{Heard at the punctum maxi- Heard at the base of the 

mum. heart, particularly at the 
left base. 

T • • J Transmitted, except the pre- Never transmitted ; occa- 

\ systolic mitral murmur. sionally heard in the neck. 

,-,, . ,, f Changes in the heart-muscle Changes in the heart-muscle 

Changes in the ] , ° n j * 

, f , ■< always occur. Hyper- do not occur. 

heart-muscle / ■,., . .. £ r ,, 

^ trophy ordilatation or both. 

Character of the f May be harsh or musical. Always soft and blowing in 

murmur \ character. 

Auscultation of Exocardial Murmurs or Pericardial Fric= 
tion Sounds. — Exocardial or pericardial murmurs are fric- 
tion sounds. They may often be diagnosticated by their 
acoustic character. They are coarser and have a grazing, 
scratching, rubbing sound, or even a sound resembling the 
creaking of new leather. Under rare circumstances pericar- 
dial friction sounds may be soft, when great difficulty will arise 
in the differential diagnosis between endocardial and exocar- 
dial sounds. 

The differential diagnosis must be made in the following 
manner : 

Endocardial Murmur. Pericardial Friction Sound. 

The endocardial murmur is heard at the The pericardial friction sounds do not 
punctum maximum. It is distinctly conform strictly to these phases ; they 

presystolic, systolic, or diastolic. may occur between, and may over- 

lap, systole or diastole. 



EXAMINATION OF THE ARTERIAL SYSTEM. 9 1 

Endocardial Murmur. Pericardial Friction Sound. 

Are often obliterated by pressure with Pressure with the stethoscope often in- 

the stethoscope. terisifies the pericardial sound. 

Are often decreased through deep in- Are increased in intensity during deep 

spiration. inspiration. 

Are transmitted. Are localized to the cardiac area, and 

have the appearance of being imme- 
diately under the ear. 
Pain usually absent. Pain present. 

The cause of pericardial friction is most frequently due to 
inflammation of the pericardium. The intensity of the friction 
sound varies greatly. It may be so loud that it is apparent 
to the patient ; on the other hand, it may be weak or entirely 
absent. 

Occasionally, a condition has been noted which has been 
called pleuropericardial friction. This may occur when the 
pleura of the left anterior border of the lung lying nearest the 
heart is inflamed so that the pericardium shares in the process. 
This may be differentiated from true pericardial friction in 
the fact that the sound is directly related to inspiration and 
expiration, disappearing as the breath is held. 



EXAMINATION OF THE ARTERIAL SYSTEM, 

Visible Pulsation. — The visible expression of the activity 
of an artery consists in the rhythmic filling of the artery syn- 
chronously with the systole of the heart, known as pulsation. 
Under normal circumstances pulsation even in the large 
arteries is scarcely visible. Changes, however, occur if the 
activity of the heart is increased. Under these circumstances 
a rhythmic beat is noted in the neck, and even the small 
arteries, such as the temporal, may show visible pulsation. 
This occurs from prolonged muscular effort, from excitement, 
in febrile conditions, and in disturbance of innervation of the 
heart's action. Visible pulsation is particularly noticeable in 
hypertrophy of the left ventricle, especially in aortic insuffi- 
ciency, which is characterized by great hypertrophy of the left 
ventricle. . 

Capillary Pulse. — This was first described by Quincke. 
Occasionally, in healthy individuals, alternate blushing and 
pallor under the nails may be noticed synchronously with the 
systole and diastole of the heart. This may also be noticed 
by briskly rubbing the skin over the forehead. The intensity 
of the capillary pulse is increased in insufficiency of the aortic 



92 PHYSICAL DIAGNOSIS. 

valves. It occasionally takes place in aneurysm of the aorta, 
and it has not infrequently been observed in chlorosis. 

Epigastric Pulsation. — Epigastric pulsation is noted below 
the xiphoid cartilage. It may be due to the pulsation trans- 
mitted from the abdominal aorta, celiac axis, or be due to the 
heart-muscle itself. Pulsation is noted in this region when 
the heart is abnormally situated. This may occur from chronic 
pulmonary emphysema, from hypertrophy of the right ven- 
tricle, from left-sided pleurisy, or from pericarditis with effu- 
sion. Visible pulsation in the epigastric region not infrequently 
occurs in hysteric and nervous individuals. A pulsation visi- 
ble in the epigastric region also takes place from aneurysm of 
the abdominal aorta. 

Pulsation from Aneurysms. — Aneurysms of superficially 
situated arteries show themselves as pulsating tumors. In 
aneurysm of deep-seated arteries a tumor only becomes visi- 
ble after the overlying parts have become indurated or moved 
aside. Care must be taken not to confound every pulsating 
tumor with aneurysms, as solid tumors may overlie an artery 
and receive transmitted pulsations ; in such cases the diag- 
nosis is made by palpation. In a tumor overlying an artery 
palpation simply reveals a rising and falling of the mass as 
the artery dilates and contracts ; whereas in aneurysm an ex- 
pansile pulsation is noted. Frequently, also, in the case of 
the aneurysm there is a systolic thrill transmitted to the 
finger. 

Transmission of Murmurs in the Arterial System. — In 
auscultating the larger arteries, such as the subclavian or 
carotid, in health two sounds are noted that resemble .the 
cardiac sounds. In auscultating the femoral artery only a 
single, dull, systolic, almost toneless sound is audible. Under 
morbid conditions murmurs may be heard in the carotid and 
subclavian arteries, as in anemia, occasionally in exophthalmic 
goiter, and in valvular disease of the heart, particularly aortic 
stenosis. 



EXAMINATION OF THE ABDOMINAL ORGANS. 

For purposes of description the abdomen is divided into 
nine regions by drawing two horizontal and two vertical lines 
over the surface. The higher horizontal line is drawn just 
below the Costal border of the ribs, and the lower one between 
the anterior superior spine of the ilium. The two vertical 



EXAMINATION OF THE ABDOMINAL ORGANS. 



93 



lines are drawn from the center of Poupart's ligament upward. 
The regions are thus divided into the right and left hypo- 
chondriac regions, the right and left lumbar regions, the right 
and left iliac regions, the epigastric region, the umbilical 
region, and the hypogastric region. 

In the right hypochondrium the right lobe of the liver with 
the gall-bladder and the hepatic flexure of the colon are found. 
More deeply situated are two- 
thirds of the duodenum, and still 
more deeply situated is the top 
of the right kidney with the 
suprarenal capsule. In the left 
hypochondrium are found the 
spleen, the splenic flexure of the 
colon, and the cardiac extremity 
of the stomach ; and more deeply 
situated is the left kidney with its 
capsule. The lumbar regions 
contain the kidneys, portions of 
the small intestines, and the 
colon. The right iliac region 
contains the cecum ; and the 
left, the sigmoid flexure of the 
colon. The epigastric region 
contains the body of the stom- 
ach, with the pyloric end, and 
the left lobe of the liver. More 
deeply situated are the pan- 
creas, celiac axis, the hepatic 

vessels, and the semilunar ganglia. The umbilical region con- 
tains in its upper part the transverse colon, and behind this 
the duodenum ; however, the greater part is made up by the 
small intestine. The hypogastric region contains the coils 
of the small intestine and the mesentery. The aorta divides 
a little to the left of the umbilicus, and a distended bladder 
or a pregnant uterus may rise into the hypogastric region. 

Inspection of the Abdomen. — This is of great importance. 
It should be. preferably undertaken with the patient first in the 
erect posture and then lying flat upon the back. The size 
and shape vary greatly in health in different individuals. A 
general enlargement may occur from subcutaneous fat of the 
abdominal walls or of the mesentery. It may be due to edema. 
Ascites causes a change in the shape of the abdomen, and it 




Fig. 8. — Lines drawn upon the sur- 
face of the abdomen, dividing it into 
regions. 



94 PHYSICAL DIAGNOSIS. 

will be noted that the shape of the abdomen changes with alter- 
ations of posture. A small quantity of fluid may only be in- 
dicated by slight bulging in the flanks. A large quantity of fluid 
increases the bulging in the flanks, but also causes a rounded 
top, and may cause the entire abdomen to become barrel shaped. 
Meteorism (distention of the bowel by gas) may cause exten- 
sive enlargement of the abdomen. Finally, enlargement of in- 
dividual organs — such as the spleen, liver, stomach, and other 
organs — and morbid growths may produce the condition. 
Retraction or a diminution in volume of the abdomen may 
occur from general emaciation, in stricture of the esophagus or 
of the cardiac end of the stomach. Movements may occur in 
the abdominal region not only from respiration, but from peris- 
talsis. Peristaltic movements are rarely visible in health. 
When present, they are usually caused by distention of the 
intestines or stomach. Pulsation may be due to aneurysm 
or to tumors and glands overlying the aorta. 

Pulsating aorta is not uncommon in anemic and in nervous 
women. A dilated condition of the superficial veins of the 
abdomen shows engorgement of the portal system, due most 
often to disease of the terminal vessels of the portal vein, or 
from pressure upon the portal vein or the inferior vena cava. 

Palpation of the Abdomen. — For the purpose of investi- 
gating diseases of the abdomen by palpation it is necessary 
that the patient should be in the dorsal decubitus, with the 
shoulders slightly raised and supported, the thighs flexed upon 
the abdomen, and the chin touching the sternum. Normally, 
the abdomen is soft, yielding readily to pressure. If it should 
prove unyielding, the administration of an anesthetic may be 
required in some instances. The physician's hand should be 
gently laid upon the abdomen, firm pressure being exercised 
after a short interval. In this manner upon deep pressure the 
kidneys, aorta, and the vertebral column may be felt. 

Resistance. — Resistance is usually due to some morbid 
condition beneath the parts palpated. It may be an important 
sign of a deep-seated lesion. Occasionally, the resistance is 
associated with swelling that may be due to muscular contrac- 
tion. In percussion over these enlargements a dull note 
may be obtained. In the majority of instances this condition 
is termed "phantom tumor," and an absolute diagnosis may 
be made by the administration of an anesthetic, when the 
tumor will disappear. This occurs particularly in neurotic 
individuals. 



EXAMINATION OF THE ABDOMINAL ORGANS. 95 

Pain. — Diffused tenderness is most frequently due to in- 
flammatory changes in the peritoneum. It may also take 
place as a manifestation of hysteria. Localized tenderness 
may result from an underlying morbid condition, such as 
appendicitis, gastric ulcer, abdominal aneurysm, etc. 

Fluctuation. — If fluctuation is present, it is usually due to 
an excess of fluid in .the peritoneum. It should be elicited in 
the following manner : One hand should be placed flat upon 
the side of the abdomen, the opposite side of the abdomen 
being tapped with the fingers of the other hand. If fluid is 
present, a wave or fluctuation is communicated to the other 
hand. This only occurs if the fluid is free in the peritoneal 
sac, and does not occur if the fluid is encysted, unless the cyst 
be veiy large. The sense of fluctuation is more marked the 
greater the amount of liquid. 

Percussion of the Abdomen. — By percussion the condition 
of the abdominal organs may be determined. The presence 
of liquid or gas, the increased size of organs, and morbid 
growths may be ascertained by this method. 

Fluid in the Abdomen. — Upon percussion a flat note is 
elicited over fluid ; and as the fluid seeks the most dependent 
part, small amounts are detected above the pubis by a flat note 
upon percussion. Larger amounts of fluid produce flatness 
in the recumbent posture, even in the hypogastric region. If 
the fluid is not encysted and free in the abdominal cavity, 
change of position produces change in note ; thus, if the 
patient is placed upon the left side, the previously present flat 
note upon the right side gives way to clearness or even tym- 
pany upon percussion. In the recumbent posture a tympan- 
itic note, with large quantities of fluid, is present in the um- 
bilical region, as the intestines are apt to float forward and 
be present in this position, the fluid having gravitated to the 
sides. If adhesions are present, the fluid may not gravitate 
with change in position, as the fluid may be shut off in this 
way from the rest of the abdominal cavity. 

A distended bladder and a pregnant uterus give rise to 
flatness upon percussion in the suprapubic region. 

Gas in the Abdomen. — When the abdomen is distended 
by gas, a uniform tympanitic note upon percussion over the 
entire abdomen is elicited. If the quantity of gas be exces- 
sive, it may obliterate the lower borders of liver dullness, 
and the spleen. 

Ascites not associated with dropsy in other localities is 



90 PHYSICAL DIAGNOSIS. 

found in acute peritonitis, tubercular peritonitis, cancer of the 
peritoneum, colloid disease of the peritoneum, chronic peri- 
tonitis, atrophic cirrhosis of the liver, and cancer of the liver. 
Ascites associated with dropsy elsewhere is the result of tri- 
cuspid disease, following left-sided valvular disease, in chronic 
pulmonary emphysema, in diseases characterized by weakness 
of the cardiac muscle, in tumors pressing upon the inferior 
vena cava, and in renal disease. 

Physical Examination of the Stomach. — Five -sixths of 
the stomach is found to the left, and only one-sixth of the 
body to the right, of the median line. The cardiac orifice is 
situated slightly to the left in front of the eleventh dorsal 
vertebra. The fundus is situated principally in the left hypo- 
chondriac region, and may be partly covered by lung, espe- 
cially when it is distended with gas. The pyloric end is situ- 
ated close to the gall-bladder. Inspection under normal 
circumstances shows nothing to indicate the situation of the 
stomach. If enlargement of the stomach takes place (gas- 
trectasis), the stomach being filled with gas, the outlines of 
the organ may be seen. The method of inflating the stom- 
ach is often practised for diagnostic purposes ; for this the 
patient is given an ordinary Seidlitz powder with very little 
fluid. Palpation reveals tender points, tumors, or enlarged 
glands in the region of the stomach. It is not possible to 
map out the size of the stomach by means of percussion. 
The position of the fundus of the stomach is of great import- 
ance in diagnosis. It is situated in the left hypochondriac 
region, and extends vertically from the sixth to the ninth car- 
tilage, and transversely from the fifth intercostal space in the 
parasternal line to the anterior axillary line. Its uppermost 
border forms a semicircle. It is bounded above by the dia- 
phragm and the apex of the heart ; upon the right, by the 
left lobe of the liver ; and upon the left, by the spleen. This 
region is known as " Traube's semilunar space." This 
space is of great importance in the differential diagnosis 
between consolidation of the base of the left lung and fluid 
in the left pleural cavity. Normally, this space has a well- 
marked tympanitic note upon percussion. If a moderate- 
sized pleural effusion occurs in the left pleural cavity, this 
space is encroached upon by the gravitation of fluid down- 
ward, and gives place to a dull or even a flat note. Consolida- 
tion of the base of the left lung does not give rise to this 
change. 



EXAMINATION OF THE ABDOMINAL ORGANS. 9/ 

Examination of the Liver. — The liver lies directly under 
the diaphragm, being held in place by the suspensory liga- 
ment, about three-fourths of it being in the right hypochon- 
drium, and only about one-fourth extending over toward the 
left. The greater portion is covered by the peritoneum. 
During expiration it rises as high as the fourth interspace, 
falling again with inspiration. The gall-bladder lies within 
the right mammillary line, where the lower border of the liver 
passes under the right border of the ribs. In children the 
liver is proportionately larger in all its dimensions. 

Inspection. — In healthy individuals no change in the con- 
tour of the abdominal wall is noted upon inspection ; only in 
very young children in the first years of life there is a slight 
bulging in the right hypochondrium, due to the larger size of the 
liver owing to physiologic fatty infiltration. Only under circum- 
stances in which the liver increases in bulk will it show signs 
upon inspection. In such instances the lower border of the liver 
may become displaced. This may also be due to displace- 
ment, and upon inspection it may be noted how the liver 
moves downward in deep inspiration. Occasionally, tumors 
may be observed in contact with the abdominal wall from the 
surface of the liver, and sometimes, although rarely, a dis- 
tended gall-bladder may be seen. 

Pulsation — due to an arterial, but more often to the venous, 
liver pulse— may be noted in the hypochondriac region. In- 
crease in the size of the liver may occur from engorgement from 
fatty or amyloid infiltration, or from obstruction of the gall- 
bladder. It takes place in certain of the acute infectious dis- 
eases, such as relapsing fever. In malignant disease an 
irregular enlargement is found. The same is true of echin- 
ococcus, of syphilis of the liver, and of abscesses in this 
organ. Downward displacement occurs most often from 
causes that depress the diaphragm, such as severe chronic 
emphysema, pleural effusions, or pneumothorax affecting the 
right side. Subphrenic abscess may have a similar result. 
Occasionally, relaxation of the suspensory ligament may give 
rise to what is called the "wandering " liver. 

Palpation of the Liver. — This is by far the most important 
method of examining the liver. The patient should be placed 
in the dorsal decubitus, and efforts made to have the abdom- 
inal wall relaxed. For this purpose the patient should be in- 
structed to open the mouth and to breathe quietly. Deep 
breathing should be insisted upon in examining the lower 
7 



98 PHYSICAL DIAGNOSIS. 

borders of the liver. Under normal conditions no part of the 
organ should be felt upon palpation. Tenderness upon palpa- 
tion is a symptom of some importance. Many diseases of the 
liver occur without tenderness upon palpation, and it is only 
when the peritoneal layer becomes involved that pain and ten- 
derness are apt to manifest themselves. Carcinoma usually 
causes pain, but it may exist without giving rise to tenderness. 
It is important upon palpation to feel for scars and tumors. 
Tumors appear in carcinoma, from echinococcus and from gum- 
mata. Scars are due most often to syphilis of the liver. 
Occasionally, in tubercular peritonitis small elevations may be 
felt at the lower border of the liver (miliary tubercles). Some- 
times by a short, sharp stroke with the hand, a thrill is com- 
municated to the other hand. This occurs from fluid in a 
cyst, and takes place in hydatid disease of the liver ; it is 
known as the hydatid thrill. Under normal circumstances the 
gall-bladder can not be felt unless there is an accumulation 
of fluid, in which case it becomes accessible to palpation. 
Occasionally, when it is filled with gall-stones, they may be 
felt through the abdominal wall. 

Percussion of the Liver. — The liver being an airless viscus, 
a flat note is obtained on percussion over the hepatic area wher- 
ever the liver comes in contact with the thoracic or abdominal 
wall. Anteriorly, liver dullness begins in the mammillary 
line at the sixth rib ; in the axillary line, at the eighth rib ; 
and in the scapular line, posteriorly at the tenth rib. It ex- 
tends from all these points to the lowest border of the costal 
cartilages. Upward displacement of the liver may be due to 
a high position of the diaphragm. Enlargement of the liver 
occurs from many causes : from malignant disease, abscess, 
echinococcus, hypertrophic cirrhosis, etc. 

Examination of the Spleen. — The spleen is situated in the 
left hypochondriac region, in the midaxillary line between the 
ninth and eleventh ribs. Under normal circumstances the 
spleen can not be palpated. Only in cases of enlargement is 
it possible to feel the spleen below the costal margin. Ten- 
derness in the splenic region occurs in the infectious diseases, 
from infarcts, new formations, or from abscess. In some dis- 
eases the spleen attains enormous size. In malarial cachexia 
and in leukemia the spleen may occupy the entire left side and 
part of the right side of the abdomen. 



EXAMINATION OF THE ABDOMINAL ORGANS. 



99 



TOPOGRAPHIC PERCUSSION. 

The limitations of the "special organs are represented by black dotted lines. 
The limits which appear dull upon deep percussion are represented by red lines. 




Fig. 9. 

A a B b y Upper anterior area of normal pulmonary resonance. 

Ddeijkng G, lower anterior area of normal pulmonary resonance. 

B A, upper posterior area of normal pulmonary resonance. 

Gpqr D, lower posterior area of normal pulmonary resonance. 

eijk, area of absolute cardiac dullness. 

ilmnk, area of relative cardiac dullness. 

F/k, lower anterior border of absolute liver flatness. 

F 'x, lower posterior border of absolute liver flatness. 

Cc, anterior border of relative liver dullness. 

Cs, posterior border of relative liver dullness. 

ptw, splenic dullness. 

hmg, Traube's semilunar space. 

wy, limit of dullness of left kidney. 

xz, limit of dullness of right kidney. [Modified from Wesener.) 



LtfC» 



IOO CLINICAL BACTERIOLOGY. 

CLINICAL BACTERIOLOGY. 

The following micro-organisms are commonly associated 
with suppuration and allied conditions : The staphylococcus 
pyogenes aureus, the staphylococcus pyogenes albus, the 
staphylococcus pyogenes citreus, the streptococcus pyogenes, 
the bacillus coli communis, the bacillus pyocyaneus, the diplo- 
coccus of pneumonia, the diplococcus intracellularis menin- 
gitidis, the ray fungus, the bacillus of glanders, and others. 
The gonococcus and the bacillus typhosus have also been 
found associated with suppurative conditions. Some lesions 
produced by the tubercle bacillus have a suppurative character. 

Staphylococcus Pyogenes Aureus. — This micro-organism 
stains readily with the ordinary anilin dyes. It does not de- 
colorize by Gram's method. This method of staining is as 
follows : ( I ) Stain the cover-glass preparation with analin- 
gentian-violet solution for half a minute; (2) wash in water ; 
(3) stam with Gram's solution (iodin, 1 part ; potassium iodid, 
2 parts ; water, 300 parts) for thirty seconds ;■ (4) wash with 
alcohol until the stain ceases to come out of the specimen ; (5) 
wash in water and mount. When examined microscopically, 
it is found in masses or clusters. Each organism is spheric in 
outline and measures about ^- of a micron in diameter. 

Biologic Characteristics. — Inoculation upon an agar slant 
reveals a growth in twenty -four hours, incubated at a temper- 
ature of 37 C. The colonies are smooth at first, have a shin- 
ing surface, and grow along the inoculation stroke, the color at 
first whitish-yellow, later becoming orange. They are cir- 
cular in outline, measuring about two millimeters in diam- 
eter. Uniform turbidity is produced when grown in bouillon. 
Stab cultures in gelatin reveal a growth in about twenty- 
four hours, liquefaction occurring in forty-eight or seventy-two 
hours, beginning at the top. Plate cultures reveal light-yellow, 
circular, and somewhat granular colonies, becoming darker as 
the growth advances. They are visible in about forty-eight 
hours after inoculation. Upon potato an abundant growth, 
having an orange color, is produced, growing at room-temper- 
ature. In litmus milk it is shown to be of an acid reaction, and 
coagulation is produced. The organism possesses marked 
resisting powers outside of the body. It requires a tempera- 
ture of 8o° C. for half an hour to produce death. 

Staphylococcus Pyogenes Albus.— The biologic and mor- 
phologic characteristics of the organism closely resemble those 



STREPTOCOCCUS CONGLOMERATUS. IOI 

of the staphylococcus pyogenes aureus except that the growth 
appears white. Both are often present in the dust, in the air, 
and upon the surface of the body. 

Staphylococcus Pyogenes Citreus. — The colonies of this 
micro-organism are of a lemon-yellow color. The virulence is 
less marked than the staphylococcus pyogenes aureus and 
albus ; otherwise the characteristics are similar to the staphyl- 
ococcus pyogenes aureus. 

Staphylococcus Epidermidis Albus (Welch). — This organ- 
ism is probably identical with the staphylococcus pyogenes 
albus. It is commonly found upon the surface of the body 
and is sometimes present in the deeper layers of the skin, 
being with difficulty reached by disinfecting agents applied to 
the surface. According to Welch, it liquefies gelatin more 
slowly, coagulates milk less rapidly, and is less virulent. It is 
a frequent cause of abscesses. 

Streptococcus Pyogenes. — Upon microscopic examination 
it is found as a coccus somewhat larger than the staphylococ- 
cus aureus, about one micron in diameter ; forming chains that 
vary in length, some being short, others, quite long. It does 
not decolorize by Gram's method, and stains readily with the 
ordinary anilin dyes. 

Biologic Characteristics. — Its growth is slow r er than the 
staphylococci, and its vitality is not so pronounced. Upon 
agar it grows along the stroke in small, circular, semitrans- 
parent, white colonies, measuring about one millimeter in 
diameter. It grows at body -temperature. Gelatin stab cul- 
ture reveals the growth along the puncture, which is white and 
appears about the second day. Liquefaction does not occur. 
It grows in bouillon. Its growth upon potato is not visible 
to the naked eye, but by microscopic examination of the 
material upon the surface it is found that the organisms grow. 
In litmus milk the growth possesses a faint acid reaction, and 
coagulation does not occur. Upon gelatin plates small, bluish- 
white, flat, rounded colonies appear in about seventy-two 
hours. Erysipelas is almost invariably due to the strepto- 
coccus. 

Streptococcus Conglomeratus. — This micro-organism con- 
sists of masses made up by chains of cocci. Free chains are 
rarely seen. It differs from the streptococcus pyogenes in 
that cultures in bouillon grown at a temperature of 37 C. 
reveal a smooth, round, and very firm white scale, or a single 
layer in the bottom of the tube that is not disintegrated when 



102 CLINICAL BACTERIOLOGY. 

the tube is slightly agitated, while the streptococcus pyogenes 
forms a loose deposit in the bottom of the tube that is easily 
broken upon slight movement. " It has been found associated 
with scarlet fever " (Kurth). 

Bacillus Pyocyaneus. — This organism measures about two 
microns in length and 0.5 micron in diameter. They are 
sometimes united in pairs or chains containing as many as six 
bacilli. The bacillus stains with the ordinary anilin dyes and 
not by Gram's method. 

Biologic Characteristics. — It is motile. Upon agar slant 
it forms an abundant growth along the stroke, which is of a 
green color. When grown in gelatin, it rapidly produces 
liquefaction of the media, and assumes a green color through- 
out. When grown upon gelatin plates, colonies first appear as 
small white points, later becoming green. Liquefaction takes 
place around the colonies. The green pigmentation produced 
by this micro-organism only appears when grown in the pres- 
ence of oxygen. According to Gessard's researches, two 
pigments are produced by this bacillus : one, a fluorescent 
green ; the other, a blue pigment. Upon potato a yellowish- 
green growth appears. 

Micrococcus Tetragenus. — This organism is a micrococcus 
measuring about one micron in diameter. It divides in two 
directions, so that groups of four (tetrads) are formed. It 
stains by Gram's method and readily with the ordinary anilin 
dyes. It grows upon culture-media, and does not liquefy 
gelatin. The colonies are of a yellowish-white color, circular 
in outline, granular, and slightly nodulated upon the surface. 
It is sometimes found in normal saliva, quite commonly in 
phthisical sputum, and in abscesses. 

Diplococcus Intracellularis Meningitidis. — These micro- 
cocci occur in pairs, sometimes in fours, or in small groups, 
and when found in inflammatory exudates, they congregate, at 
times, inside of the pus-corpuscles. The organism is round or 
oval, resembling somewhat the gonococcus. It does not stain 
by Gram's method, but is demonstrated by Loffler's alkaline 
methylene-blue solution. At body-temperature it grows upon 
agar or glycerin-agar, forming colonies of a yellowish-brown 
color surrounded by a transparent zone. It does not grow 
well in bouillon or in blood-serum. It grows upon potato. 
This micrococcus was discovered by Weichselbaum in the 
exudates of cerebrospinal meningitis in 1887. 

The Gonococcus. — This micrococcus is somewhat oval in 



DIPLOCOCCUS LANCEOLATUS. IO3 

shape, and grows in pairs. The pair of cells may be com- 
pared to two beans placed side by side so that the concavities 
form the inner borders. This organism stains readily with 
the ordinary anilin dyes, and not by Gram's method. When 
found in pus, it frequently occupies the pus-cells, which is of 
importance in diagnosis. Artificial cultivation is difficult. It 
grows upon blood-serum, particularly human serum, at a tem- 
perature of- from 30 C. to 34 C. The color of the growth 
upon blood-serum is found to be grayish-yellow, is very 
thin, scarcely visible, and reaches its maximum growth upon 
culture-media after two or three days, when no further devel- 
opment occurs, and it soon loses its vitality. The gonococ- 
cus is killed when exposed to a temperature of 6o° C. 
This micro-organism was discovered by Neisser in 1879, ob- 
tained from gonorrheal pus. It is always present in the dis- 
charge from gonorrhea, whether it be from the genital tract or 
from other parts of the body. When affecting the mucous 
membrane, the gonococcus penetrates between the epithelial 
cells and is sometimes found in the layers beneath the epithe- 
lium. It is associated with urethritis, cystitis, suppuration of 
the kidneys, salpingitis, arthritis, endocarditis, and other con- 
ditions. 

Diplococcus Lanceolatus (Frankel's Pneumococcus). — 
These organisms exist as oval cocci, and are found in pairs, 
sometimes in chains. A transparent capsule is sometimes 
noted surrounding the pairs in stained preparation. It stains 
by Gram's method and with the ordinary anilin dyes. (Fig. 10.) 

Biologic Characteristics. — It is easily cultivated on the 
ordinary culture-media, particularly when having a slight alka- 
line reaction, growing best at 37 ° C. or at room-temperature. 
It does not liquefy gelatin. The thermal death-point is 5 2° C. 
for an exposure of ten minutes. Upon blood-serum the colo- 
nies appear as transparent pellicles along the stroke of the 
needle. As a rule, it does not grow upon potato. 

This micro-organism was described by Sternberg in 1880, he 
having inoculated some of his own saliva subcutaneously in 
rabbits, thus producing septicemia. Pasteur also described it in 
1880. It is found associated with croupous pneumonia ; this 
was demonstrated by Frankel, Weichselbaum, Sternberg, and 
others. It is usually present in normal saliva, and is the 
most frequent organism found in the sputum of individuals 
suffering from croupous pneumonia. It has also been found 
in the inflammatory exudate in meningitis, ulcerative endo- 



104 CLINICAL BACTERIOLOGY. 

carditis, otitis media, and other conditions. In cases of 
croupous pneumonia caused by the diplococcus lanceolatus 
many of the general symptoms are due to the toxins elimi- 
nated from this organism ; it is usually only confined to 
the lung. 

The Bacillus of Friedlander. — This micro-organism is 
a short bacillus having rounded ends, often resembling a 
micrococcus ; they are sometimes united in pairs or chains. 
A capsule surrounds the organism when preparations are 
made from blood inoculated with this micro-organism. This 
capsule can not be demonstrated when taken from cultures in 
artificial media. It stains quite readily with the anilin dyes, 
and decolorizes by Gram's method. It grows upon the ordi- 




Fig. 10. — Diplococcus pneumoniae ; X iooo. 

nary media. Upon gelatin plates at the end of twenty-four 
hours small white spheric colonies appear. The thermal death- 
point is 56 C. The organism is nonmotile and does not 
liquefy gelatin. It is aerobic, and facultative anaerobic. It 
grows upon potato. The colonies are yellowish-white in color. 
In gelatin stab cultures the growth presents a nail-like appear- 
ance, the line of the stab revealing a white growth, and the 
growth is heaped up upon the surface of the gelatin. Occa- 
sionally, gas is produced. This organism is sometimes asso- 
ciated with croupous pneumonia, but much less frequently 
than the diplococcus of pneumonia. 

The Bacillus of Tuberculosis. — This micro-organism 
measures from one and one-half to three and one-half microns 



BACILLUS OF TUBERCULOSIS. 105 

in length, and about ^ of a micron in diameter. The bacil- 
lus is straight or slightly curved (bent at an angle). It may be 
solitary, united in pairs, or sometimes in short chains ; rarely, 
branching forms are met with. The staining reaction of the 
bacillus tuberculosis is quite characteristic inasmuch that it 
takes up stain with difficulty. Powerful staining solutions 
should be employed, as solutions of gentian-violet or fuchsin 
containing an anilin oil, or carbolic acid. The stain must be 
applied for a long period of time, or staining may be promoted 
by the application of heat. When the bacillus is stained, it 
resists decolorizing agents, such as 20 c / c solutions of sul- 
phuric or nitric acid. It is stained by Gram's method. 
A very satisfactory stain that is generally employed is Ziehl- 




Fig. 11. — Bacillus tuberculosis in sputum ; X 1000. 

Neelsen's carbol-fuchsin (saturated alcoholic solution of 
fuchsin, 10 parts ; and a 5 c f c carbolic acid water, 90 parts). 
After staining with this solution the fluid is washed off with 
water, and then treated either with the strong solution (20^) 
of sulphuric or nitric acid until decolorized, or with Gabbet's 
methylene-blue solution for about thirty seconds. This solu- 
tion consists of methylene-blue, 2 parts ; sulphuric acid, 25 
parts ; and water, 75 parts. When using Gabbet's solution as 
a contrast stain, the tubercle bacilli will appear red, while other 
micro-organisms will be stained blue. The smegma bacillus 
and the lepra bacillus resemble the tubercle bacillus as regards 
staining reaction. The latter can be differentiated from the 
smegma bacillus from the fact that it does not decolorize when 



106 CLINICAL BACTERIOLOGY. 

treated with alcohol. As a rule, this test need not be applied 
unless dealing with an examination of the urine. The tuber- 
cle bacillus is differentiated from the bacillus of leprosy in that 
it is somewhat shorter and retains the stain more firmly than 
the latter. Confusion between the two bacilli does not often 
occur. 

Biologic Characteristics. — This bacillus shows marked 
resisting powers, and retains its vitality for a long time under 
various conditions. It this respect it resembles bacteria that 
form spores. The question of spore -formation, however, has 
not been determined in this organism, but it seems probable 
that it does form spores. After an exposure of two months 
sputum has been found to contain virulent bacilli. In the 
dried condition, when subjected to a temperature of ioo° C. 
for an hour, the bacilli retain their vitality. The temperature 
of 70 ° C. in a moist chamber for a short time is usually fatal 
to the organism. A 5 ft solution of carbolic acid is fatal to the 
bacillus when exposed for five minutes. The organism can be 
cultivated upon blood-serum, a growth resulting in about two 
weeks that consists of small dried scales of a whitish or bluish 
color. The outline of the colonies is somewhat irregular and 
scattered over the surface of the media. They can also be 
cultivated in glycerin broth or glycerin agar, the most suitable 
temperature for growth being 37 ° C, but they can not be cul- 
tivated upon the ordinary gelatin or agar media. 

This micro-organism was discovered by Koch in 1882. It 
is usually found in the sputum of those suffering from tuber- 
culosis of the lungs, and often in the feces when tuberculosis 
of the intestinal tract is present ; in the urine, when the infec- 
tion occurs in relation to the genito-urinary apparatus. In the 
lesions produced by the tubercle bacillus it is commonly situ- 
ated in the cheesy mass, giant cells, and epithelioid cells. 
When necrosis is well advanced, it is sometimes absent in the 
center of the caseous substance. Tuberculosis is one of 
the most common of all diseases met with, not only affecting 
man, but many of the lower animals, such as cattle, horses, 
birds, etc. 

Koch, in 1890, introduced a substance called tuberculin as 
probably being of use as a curative agent. It has, however, 
proved itself to be of no value in this connection, but of great 
use in diagnosis. Tuberculin consists of filtered products from 
old fluid cultures, the bacilli having been killed by heat. Tuber- 
culin when injected into healthy animals produces no ill effects, 



BACILLUS OF GLANDERS. IO/ 

but when injected into a tuberculous subject, produces a marked 
reaction, particularly the appearance of fever. 

The Bacillus of Leprosy. — This bacillus measures from 
four to six microns in length and about one micron in diame- 
ter. It occurs in straight rods, sometimes bent or curved. It 
stains with the ordinary anilin dyes, taking up the stain with 
difficulty, but retaining it when treated with strong acid solu- 
tion. It retains Gram's stain. 

Biologic Characteristics. — Like the tubercle bacillus, this 
micro-organism stains with carbolfuchsin, and should be treated 
subsequently with a strong solution (20^) of nitric acid, or 
Gabbet's solution. (For points of differentiation between this 
organism and the tubercle bacillus refer to the Bacillus of 
Tuberculosis.) 

This micro-organism has never been cultivated upon artificial 
media. The bacillus is nonmotile. Leprosy has been pro- 
duced experimentally by the inoculation of the bacillus into 
criminals. It was first described by Hansen in 1871, and 
since that time the discovery has been confirmed by other 
observers. 

The Bacillus Mallei (the Bacillus of Glanders).— This 
bacillus is straight or slightly curved, and about the same 
length as the bacillus of tuberculosis. It stains quite readily 
with the ordinary anilin dyes. It is easily decolorized by acid 
solutions, also by Gram's method. 

Biologic Characteristics. — This bacillus is nonmotile, aero- 
bic, and grows best at a temperature of 37 C. It can be 
cultivated upon various forms of artificial media. It loses its 
vitality when exposed to a temperature of 5 5 ° C. for five min- 
utes, or when treated with a 5 % solution of carbolic acid. 
Upon agar it produces an extensive growth in about two days. 
This growth is thick and white in appearance ; after three or 
four days the color becomes amber yellow. Upon blood- 
serum it forms a yellow, transparent, drop-like colony. It also 
grows quite readily in bouillon, upon potato, and does not 
liquefy gelatin nor blood-serum. This bacillus was dis- 
covered by Loffler and Schultz in 1882, and was found in 
the tissues of animals suffering from glanders. The sub- 
stance of use in diagnosis of glanders is known as mallein, 
which bears the same relation to glanders that tuberculin does 
to tuberculosis. Mallein is prepared from old glycerin bouillon 
cultures. This culture is filtrated, and the product 'is the 
substance used. When subcutaneously injected into animals 



108 CLINICAL BACTERIOLOGY. 

suffering from glanders, a reaction is produced in from four to 
ten hours. 

The Bacillus of Anthrax. — The appearance of this bacil- 
lus, when obtained from bouillon cultures, is as follows : It 
grows in chains, each bacillus measuring from one to one and 
one-half microns in breadth, and from five to twenty microns 
in length. It is a straight bacillus with rounded ends, and 
it stains with the ordinary anilin dyes and also by Gram's 
method. It produces spores. 

Biologic Characteristics. — It is a nonmotile aerobic micro- 
organism, and grows in a variety of culture-media at a tem- 
perature of from 20° C. to 38 ° C. Upon gelatin plates, 
colonies are developed that are irregular in outline and of a 
greenish color, developing in from twenty -four to thirty-six 
hours. Mycelium-like outgrowths are often seen extending 
from the periphery of the growth into the surrounding gela- 
tin. When grown in gelatin, liquefaction takes place' at the 
end of two or three days. Upon nutrient agar a grayish- 
white growth is produced at the end of twenty-four hours. 
When grown upon blood-serum, this media is liquefied. 
Spores are only produced in the presence of oxygen. At a 
temperature of 54 C, when exposed for ten minutes, this 
micro-organism loses its vitality if spores are not present ; 
the spores, however, show great resisting powers. This 
bacillus was first obtained in the blood of infected animals by 
Pollender in 1849. 

Bacillus Typhosus. — This bacillus measures from one to 
three microns in length, and from about t 5 q- to T 8 ^ of a micron 
in breadth. Its ends are rounded. Around the periphery of 
the bacillus there are numerous flagella, numbering from five 
to twenty. These flagella are about five times the length of 
the bacillus, and about T \j of a micron in breadth. It stains 
with the ordinary anilin dyes and easily decolorizes. Special 
methods of staining are necessary to demonstrate the flagella, 
which are more numerous in the bacillus typhosus than in the 
bacillus coli communis. 

Biologic Characteristics. — When this * organism is inocu- 
lated upon agar media, colonies, circular in outline, are produced 
in about twenty -four hours, of a bluish-gray color when held to 
the light (transmitted light), and a dull white by reflected light. 
When grown in gelatin, liquefaction is not produced. It 
grows readily in bouillon. When examined in the hanging 
drop, it is found to be actively motile, old cultures being less 



BACILLUS TYPHOSUS. IO9 

active. It develops best at a temperature of 37 ° C, and is 
killed after an exposure of half an hour at 60 ° C, and after 
two or three minutes at ioo° C. Freezing does not destroy 
it. Upon potato, the growth is quite characteristic. At the 
end of twenty-four or forty-eight hours the surface appears 
velvety and of a dull white appearance. In litmus milk the 
culture is found to be alkaline in reaction, and coagulation is 
not produced. It does not produce gas when grown in agar 
media containing lactose, and does not produce indol. The 
bacillus was discovered by Eberth in 1880, who demonstrated 
its presence in the spleen and mesenteric glands. 

The Widal Reaction. — When the blood of an individual 
suffering from enteric fever is mixed with a twenty-four-hour 




Fig. 12. — Bacillus typhosus; X iooo. 

old bouillon culture of the bacillus typhosus, a marked reac- 
tion occurs that consists in the loss of the motility of the 
micro-organism, and clumping or grouping of the bacilli. A 
drop or two of blood should be obtained. This is collected 
upon a clean sheet of paper or upon a glass slide, and allowed 
to dry. The dried film may be preserved for a long period 
of time. The dried blood should be dissolved with sterilized 
water and mixed with the bouillon culture in the proportion 
of one part of blood to from twenty to fifty parts of the cul- 
ture and water. This mixture should be placed upon a cover- 
glass, and mounted upon the hollow-ground slide as a hang- 
ing drop. If the reaction be positive, stoppage of motility 
and clumping will occur during the course of half an hour ; if 



IIO CLINICAL BACTERIOLOGY. 

the reaction be negative, the bacilli will neither lose their 
motility nor clump. The reaction is found to be positive in 
about 95^ of the cases of enteric fever. The blood in some 
diseases (miliary tuberculosis) occasionally gives the reaction. 
A pseudoreaction may occur, which consists in slight clump- 
ing and diminished motility. This is not indicative of enteric 
fever. 

The Bacillus Coli Communis. — This micro-organism ap- 
pears in short rods with rounded ends, the length varying 
somewhat between two and three microns, and its breadth 
measures about t 5 q- of a micron. It does not produce spores. 
The bacilli are sometimes linked in pairs or short chains. It 
is supplied with flagella, numbering from two to ten, and is 
motile, but not so active as the bacillus typhosus. It stains 
with the ordinary anilin dyes and decolorizes by Gram's 
method. 

Biologic Characteristics. — This micro-organism grows 
readily upon the ordinary forms of culture-media, growing 
best at about 37 ° C, the thermal death-point being 60 ° C, 
when exposed for ten minutes. Upon agar and blood-serum, 
at the end of twenty-four hours a thick, moist, grayish- 
white layer is formed upon the surface. Upon gelatin plates 
colonies are noted at the end of twenty-four hours, and 
appear as spheric masses of a brownish color, the darkest 
shade being near the center of the colony. Superficial 
colonies are sometimes round or irregular in outline, and 
measure about three millimeters in diameter. The organism 
does not liquefy gelatin. Stab cultures in sugar agar and 
shake gelatin cultures produce gas-formation. When grown 
upon potato, a luxuriant growth, which is of a brownish-yellow 
color, is noticed at the end of twenty-four or forty-eight hours. 
When grown in litmus milk, coagulation appears, the media 
changing its color to red, demonstrating an acid reaction. The 
micro-organism also produces indol. It is normally found in 
the intestinal canal, and when it gains access to tissues, inflam- 
matory lesions are produced. It is a frequent cause of peri- 
tonitis, appendicitis, and infections due to strangulation of the 
bowel, etc. It has been found in pneumonic exudates, pleurisy, 
and endocarditis. It is also associated with inflammations of 
the genito-urinary tract, such as cystitis. It is frequently met 
with in abscess-formation. A number of varieties of the colon 
bacillus have been described. It must be remembered that 
the bacillus typhosus closely resembles this organism, and by 



BACILLUS OF DIPHTHERIA. Ill 

some it is regarded that the two are indistinguishable ; how- 
ever, experiments have shown that the colon bacillus and the 
bacillus typhosus under similar conditions can not be trans- 
formed from one into the other, each organ retaining its own 
characteristics. The main differences between the bacillus ty- 
phosus and the bacillus coli communis are the following : 

Bacillus Coli Communis. Bacillus Typhosus. 

Flagella fewer in number. Flagella numerous and longer. 

Slight motility. Active motility. 

Decolorizes by Gram's method. Decolorizes by Gram's method. 

Growth upon culture-media vigorous. Growth generally less rapid and not so 

abundant. 

Does not liquefy gelatin. Does not liquefy gelatin. 

Growth upon potato brownish-yellow Growth upon potato nearly transparent. 

and luxuriant. 

Acid production marked. Produces an alkaline or very slightly 

acid reaction. 

Coagulation marked. No coagulation. 

Indol production marked. Indol production absent. 

Gas production marked. Gas production absent. 

Clumping absent when mixed with Agglutination with typhoid serum posi- 

typhoid serum. tive. 

The colon bacillus was obtained by Emmerich in 1885. 

The Bacillus of Diphtheria. — This micro-organism ap- 
pears as a bacillus having rounded ends, and measures about 
three microns in length and t 5 q- of a micron in diameter. It is 
straight or slightly curved, varying considerably, depending 
upon artificial cultivation. When grown upon agar, the or- 
ganism is larger than when grown in broth. Upon serum 
and gelatin the organisms are of medium size. The bacillus 
stains with the ordinary anilin dyes, Loffler's alkaline methyl- 
ene-blue solution readily staining the organism. The formula 
for this solution is as follows : Saturated alcoholic solution of 
methylene-blue, 30 c.c. ; solution of caustic potash in water 
(1 : 10,000), 100 c.c. . When stained with this solution, quite 
a characteristic appearance is noticed, the bacillus staining 
irregularly, there being areas that are deeply stained alternat- 
ing with paler stained areas, giving the bacillus a beaded or 
dotted appearance ; sometimes they stain uniformly. It is 
not decolorized by Gram's method. Spores have not been 
demonstrated. 

Biologic Characteristics. — This organism is aerobic, but 
also facultative anaerobic. It is nonmotile, and grows upon 
the ordinary culture -media, but increases best, however, upon 
blood-serum, more rapidly upon this medium than other 



I I 2 CLINICAL BACTERIOLOGY. 

micro-organisms. Upon blood-serum a luxuriant growth is 
noticed at the end of twenty-four hours, colonies developing 
that are round, elevated masses of a grayish-yellow color, 
the center being darker than the periphery, which is some- 
what irregular. The bacillus does not liquefy gelatin, and 
grows slowly upon this medium. It produces an acid reac- 
tion during the earlier part of its growth, which later becomes 
alkaline. It does not produce gas. The indol reaction is 
present in cultures. Its thermal death-point is 54 C. when 
exposed for ten minutes. It grows best at 37 ° C. 

This bacillus produces certain well-marked pathologic 
changes : the production of pseudomembrane, the most com- 
mon situation of this being the pharynx, uvula, and tonsils ; 




Fig. 13. — Bacillus diphtherias ; X iooo. 

however, many other situations may be mentioned, such as 
the posterior nares, the bronchi, and the skin. It is found in 
the membrane, upon the free surface of it, and in the tissues 
beneath the membrane, but does not extend very deeply. 

The toxins eliminated by this organism produce certain 
well-marked changes, the most common being cloudy swell- 
ing of various organs, particularly of the kidney, congestion 
of various organs, hyaline degeneration of the blood-vessels, 
and certain nerve-lesions. 

The virulence of the diphtheria bacillus varies, and it 
should be remembered that this organism is often found in 
the mouth long after the inflammatory lesions have subsided. 

This bacillus was first observed by Klebs in 1883, and 



BACILLUS OF TETANUS. I I 3 

later, in 1884, by Loffler, who isolated the organism and dem- 
onstrated its pathogenic power. 

Animals, especially horses, may be rendered immune by 
the gradual injection of diphtheria toxins. 

The toxins are procured by filtering cultures possessing a 
high degree of toxicity through a Pasteur-Chamberlain filter. 
The first injection of the toxins into horses produces a marked 
reaction. The dose of toxin is gradually increased at each 
injection, and after some time the serum of the horse pos- 
sesses marked antitoxic properties. This antitoxin is of great 
value in the treatment of diphtheria. 

In the preparation of a curative serum, the toxin should 
be of such a strength that a guinea-pig weighing 250 grams 
will be killed on the fourth or fifth day after the injection. 
When ten times the minimum fatal dose of toxin is neutral- 
ized by the injection of o. 1 c.c. of antitoxin into a guinea- 
pig, this is designated as normal serum ; 1 c.c. of this 
serum contains a normal antitoxin-tinit. When 0.0 1 c.c. of 
antitoxin protects an animal from ten times the fatal dose of 
toxin, 1 c.c. of this serum contains 10 antitoxin-units. If 
only o.OO 1 c.c. is required, then 1 c.c. of such a serum repre- 
sents IOO antitoxin-units. 

Pseudodiphtheria Bacillus. — This bacillus possesses very 
slight pathogenic properties. It is sometimes found in anginal 
lesions. It measures between one micron and two microns 
in length, and the ends are rounded and slightly thicker than 
the remaining part of the bacillus. It stains with the ordinary 
anilin dyes, and the staining reaction is regular. It is stained 
by Gram's method. It does not form spores and is nonmotile. 
The growth upon agar, serum, and gelatin closely resembles 
that of the diphtheria bacillus. Slight growth is noticed 
upon ordinary potato. It does not produce gas in stab 
cultures. The growth produces an alkaline reaction. It is 
nonliquefying and does not coagulate milk. When grown in 
peptone media the indol reaction is produced in about three 
weeks. Sulphuric acid must be added to obtain the reaction. 
The indol reaction is obtained with the cultivation of the diph- 
theria bacillus in about a week. The organism is nonpatho- 
genic to guinea-pigs when administered in doses of 5 c.c. of 
a forty-eight-hour broth culture. 

The Bacillus of Tetanus. — This micro-organism appears 
as a straight, slender bacillus with rounded ends, measuring 



114 CLINICAL BACTERIOLOGY. 

about four or five microns in length, and -^ of a micron in 
diameter, and when spores are formed it presents a thickening 
at one end, so that the organism may be compared to the 
shape of a pin or a drumstick. It is motile, possessing a 
number of flagella. It stains with the ordinary anilin dyes 
and by Gram's method. 

Biologic Characteristics. — The organism readily forms 
spores. It is anaerobic, and grows best at the temperature 
of about 37° C. upon gelatin, agar, and blood-serum. The 
bacillus of tetanus possesses marked degrees of resisting 
power. The spores do not perish when exposed to a tem- 
perature of 80 ° C. for an hour in the dried state. When ex- 
posed to carbolic acid (1 : 20), it is destroyed only after fifteen 




Fig. 14. — Bacillus tetani ; X iooo. 

hours. It must be cultivated in a stream of hydrogen, being 
distinctly anaerobic. The growth possesses a feeble alkaline 
reaction. The stab culture in gelatin reveals a growth in the 
central puncture that has an opaque appearance. It slowly 
liquefies the media, and may be grown at a temperature of 
22 C. Sometimes a small amount of gas is produced 
around the puncture. 

Kitasato in 1889 obtained the micro-organism in pure cul- 
ture. Nicolaier in 1884 produced tetanus in mice by inocu- 
lation of garden earth, and also demonstrated that the disease 
could be transmitted by inoculation to other animals. 

The toxins elaborated by the tetanus bacillus possess a high 



BACILLUS OF MALIGNANT EDEMA. I I 5 

degree of virulence. The quantity necessary to kill a mouse 
is 0.0000 1 c.c. of a filtrate obtained from bouillon culture. 

The tetanus bacillus is found in garden soil, where it proba- 
bly leads a saprophytic existence. It gains access to the body 
through a wound or a slight abrasion, the lower extremities 
being frequently affected. (Idiopathic tetanus probably does 
not exist, this term having been applied when the channel of 
infection had not been determined.) 

Microscopic examination of scrapings or a section from a 
wound usually reveals numerous bacilli. 

The tetanus bacillus is differentiated by its drumstick ap- 
pearance when spore formation has taken place. There would 
be no doubt of the identity under such circumstances. If the 
wound be contaminated by other bacteria and the tetanus 
bacillus does not show spore formation, the diagnosis by the 
microscope will be impossible, and under such circumstances 
cultivation and inoculation experiments must be resorted to in 
order to demonstrate the bacillus. 

The general symptoms of tetanus are due to the virulent 
toxins, which have an elective action upon the spinal cord. 
The toxic power of the urine is greatly increased in tetanus. 

Antitetanic Serum. — This serum is made by the injection 
of toxins into a horse. The principles of preparation are 
about the same as those used in the making of the antidiph- 
theric serum. This serum is used in the treatment of tetanus ; 
the results, however, have not been nearly so good as in the 
treatment of diphtheria by the diphtheria antitoxin. 

The Bacillus of Malignant Edema. — This bacillus some- 
what resembles the bacillus of anthrax in regard to size. It 
measures about 3^ microns in length and iy 1 ^- microns in 
diameter. Sometimes the bacillus is much longer, measuring 
from 15 to 40 microns. The bacillus is straight, occasion- 
ally somewhat curved. It produces spores that are centrally 
located in the bacillus, producing a central swelling. It stains 
with the ordinary anilin dyes, and not by Gram's method. 

Biologic Characteristics. — The bacillus is anaerobic, being 
best grown in a stream of hydrogen. It is motile. When 
grown upon nutrient agar at the ordinary room-temperature, 
the colonies are irregular in outline and present a white ap- 
pearance. It liquefies gelatin and blood-serum. When 
grown on blood-serum, gas production is noted. This bacil- 
lus was first described by Pasteur, who called it " vibrion 
septique!' It is associated with spreading inflammatory con- 



Il6 CLINICAL BACTERIOLOGY. 

editions attended by edema and emphysema of the skin, often 
terminating in gangrene. This bacillus is found in garden soil 
and putrefying animal fluids. Immunity may be induced by 
the gradual injection of the toxins into susceptible animals. 

Spirillum of Cholera. — This micro-organism appears in 
slightly curved rods resembling a comma, hence the name, 
"comma bacillus of Koch." Sometimes these are united in 
pairs, forming a circle or an S-shaped figure. The spirillum 



measures about one or two microns in length, and about t 3 q- 
or y^ of a micron in diameter. It stains with the ordinary 
anilin dyes, and is decolorized by Gram's method. 

Biologic Characteristics. — This spirillum is motile, possess- 




Fig. 15. — Comma bacilli (from the mouth) ; X 1000. 

ing a single terminal flagellum. It does not form spores, is 
aerobic, and grows upon the ordinary forms of culture-media, 
which should have a slight alkaline reaction at about room- 
temperature, but more readily at 37 ° C. The thermal death- 
point is 5 5 ° C. when exposed for one hour. A temperature 
of — 100 C. does not destroy its vitality when exposed for sev- 
eral hours. On gelatin plates colonies appear in from twenty- 
four to forty -eight hours. They are granular, of a white 
color, and circular in outline. Liquefaction of the media soon 
occurs, giving the area a cup-like depression. In a gelatin 
stab culture liquefaction is produced, the micro-organism 
growing along the stroke. Upon blood-serum liquefaction of 
this media results. It grows upon potato at the temperature 



SPIRILLUM OF RELAPSING FEVER. 117 

of 37° C, producing colonies of a grayish-brown color. It 
does not coagulate milk. When grown in peptone media, and 
a few drops of sulphuric acid are added to the culture, a red 
color is produced, called the "cholera red reaction." This 
spirillum was described by Koch in 1884 in the excreta of a 
patient suffering from cholera, and was also found in the intes- 
tines of those having died of this disease. In patients suffering 
from cholera this micro-organism is confined to the intestines, 
occurring there in enormous numbers and in almost pure cul- 
tures. It has not been found in the blood or in the internal 
organs. Immunity may be induced in the guinea-pig by 
gradual injections of nonfatal doses of culture. The serum 
will give a specific agglutination test when mixed with the 




Fig. 16. — Spirilla of relapsing fever in human blood ; X iooo. 

pure culture of the cholera spirillum in the proportion of 
1 : 20 to 1 : 100. 

Spirillum of Relapsing Fever. — The spirillum of relaps- 
ing fever appears in the peripheral blood of patients suffering 
from this condition, during the febrile paroxysms, and disap- 
pears during the intermissions. It is a long, slender, spiral 
organism measuring from fifteen to forty microns in length, 
arid possessing active motility. It is best studied by examin- 
ing the fresh blood during the febrile paroxysm. It stains 
with the ordinary anilin dyes and decolorizes by Gram's 
method. This organism has never been cultivated upon arti- 
ficial media. It has been kept alive for a few hours by placing 
the infected blood into tubes and sealed. The thermal death- 



Il8 CLINICAL BACTERIOLOGY. 

point is 6o° C, but a temperature of o° C. does not destroy 
their vitality. The disease has been produced experimentally 
by the inoculation of blood from individuals suffering from 
relapsing fever into apes, the period of incubation then being 
about three days, followed by a period of pyrexia that lasts 
from two to three days, ending by crisis. Usually no relapses 
result. Phagocytosis is clearly demonstrated in this disease. 
During the period of apyrexia the organisms probably accu- 
mulate in the spleen, where they are also destroyed. Ober- 
meier in 1873 discovered the spirillum (spirochete Ober- 
meieri) in the blood of patients suffering from relapsing fever. 
The disease has been produced in the human subject by 
inoculation with the blood infected by this micro-organism. 

Metschnikoffs Spirillum. — This micro-organism closely 
resembles the spirillum of cholera in its biologic and morpho- 
logic characteristics, except that when injected subcutaneously 
into pigeons, inflammatory swelling occurs with manifestations 
of septicemia, and death takes place within twenty -four hours, 
which does not occur with the spirillum of cholera. It does 
not give the agglutination test when mixed with the serum 
of patients suffering from cholera, showing that the anti- 
cholera serum exerts no properties against this organism. 
This micro-organism was obtained by Gameleia from the 
intestinal contents of fowls. 

The Spirillum of Finkler and Prior. — This spirillum was 
obtained from the stools of certain cases of cholera nostras ; 
however, its relationship to this disease has not been demon- 
strated. Morphologically, it resembles the spirillum of 
cholera. Its biologic properties are different, in that it grows 
more rapidly. Liquefaction is noted at the end of twenty- 
four hours. Individual colonies upon gelatin plates are often 
of large size and produce marked liquefaction. The cholera 
red reaction is not obtained from the growth in peptone solu- 
tions. A fetid odor is produced from the growth of this 
micro-organism. 

The Bacillus of Influenza. — This micro-organism meas- 
ures about i|- microns in length, and ^ of a micron in 
diameter, appearing in straight rods with rounded end's. 
They are usually solitary, but may be united in groups of 
three or four. The bacillus stains with the ordinary anilin 
dyes, and is decolorized by Gram's method. 

Biologic Characteristics. — This bacillus is aerobic. It does 
not form spores and is nonmotile. It grows at 37 ° C, 



BACILLUS PESTIS. II9 

colonies appearing upon blood-serum in twenty-four hours, 
which are circular in outline and almost transparent It 
may be grown upon glycerin agar, drop-like colonies de- 
veloping that are almost transparent, and do not tend to join 
together, but have a distinct property of remaining separated 
from one another. It is cultivated with difficulty in bouillon, 
growing more readily if blood be added to the media. It 
does not grow in gelatin. Its thermal death-point is 6o° C. 
when exposed for five minutes. This bacillus was discovered 
by Pfeiffer in 1892 in patients suffering from influenza. It 
has been isolated from the bronchial and nasal secretion, from 
the lungs (in cases of pneumonia), and other organs, but it is 




Fig. 17. — Bacillus pestis (Yersin). 

rarely present in the blood. In cases of influenza the micro- 
organism is most frequently present in the bronchial secretion. 

The Bacillus Pestis. — This bacillus occurs in short rods 
with rounded ends, measuring 2^- microns in length, and iy^ 
microns in diameter ; it is almost oval. It stains readily with 
the ordinary anilin dyes, but does not retain its color when 
treated by Gram's method. In stained preparations it is often 
noted that the ends are more deeply colored than the central 
portion, giving rise to the so-called "pole-staining." The 
bacilli are frequently found in chains. 

Biologic Characteristics. — It is grown best at 37 C, 
but it may be cultivated at a temperature as low as 18 C. 
Its thermal death -point is 58 ° C. when exposed for several 
hours. The organism sometimes occurs encapsulated, but 



120 CLINICAL BACTERIOLOGY. 

this has not been noted by all observers. It does not possess 
motility. Upon agar media the colonies are circular in outline, 
slightly raised, and of a creamy color. They are somewhat 
granular, and the margins are quite regular. In stab gelatin 
cultures the medium is not liquefied, and the growth along 
the inoculation is not well marked. Gas is not produced when 
grown in sugar agar media. It does not coagulate milk, 
and produces a feeble indol reaction in broth cultures a 
week old on the addition of sulphuric acid. A well-marked 
acid reaction is noted when grown upon nutrient litmus agar. 
This bacillus was discovered independently by Kitasato and 
Yersin in 1894, during an epidemic at Hong Kong. The 
bacilli are found in the diseased lymphatic glands in great num- 
bers, sometimes in the blood, and they have also been noted 
in the liver, kidneys, spleen, lungs (producing plague pneu- 
monia), and in many other organs. Infection by this micro- 
organism produces a high mortality, not only in man, but also 
in certain animals, particularly rats and mice. Immunity in 
rabbits has been produced by the gradual injection of cultures 
that have been killed by heat ; the serum of such immune 
animals possesses certain protective powers. Antiplague 
serum obtained from immunized horses has been employed 
with favorable results. 

The Bacillus Icteroides. — This micro-organism measures 
between two and four microns in length and t 5 q- of a micron in 
breadth, and has rounded ends. It stains with the ordinary 
anilin dyes, but loses its color when treated by Gram's method. 

Biologic Characteristics. — The bacillus is motile, having 
from four to eight flagella. It does not liquefy gelatin, and 
can be cultivated upon the usual forms of media, growing best 
at a temperature of 37 C. Upon an agar slant a growth will 
be noticed in twenty-four hours, the colonies being somewhat 
transparent and of a glittering gray color. On transferring 
the growth to a lower temperature for about twelve hours, the 
periphery of the colonies will exhibit a white or pearly-brown 
color, and are raised somewhat higher than the central por- 
tion ; after a few days this growth becomes somewhat liquid, 
and may run down the sides of the media. Upon gelatin 
plates a growth will be noticed in twenty-four hours. Col- 
onies appear as transparent points, and after the growth has 
existed for about seven days, the central portion of the colony 
becomes opaque. The cultures give a feeble indol reaction. 
When grown in milk, coagulation is slowly produced. Glu- 



ACTINOMYCES. 12 1 

cose is fermented. The bacillus may also be cultivated upon 
blood-serum, potato, and in bouillon. This micro-organism 
was discovered by Sanarelli, who obtained it in cultures from 
cases of yellow fever in 1897. Sternberg in 1890 obtained a 
bacillus known as the bacillus " X," from various organs of 
cases suffering from yellow fever, which appeared to have some 
causative relationship to the disease. This micro-organism is 
probably identical with the one described by Sanarelli. The 
bacillus icteroides can be obtained from the liver and kidneys 
of persons suffering from yellow fever. Other micro-organisms 
may be associated with it. These are due to secondary infec- 
tion. The mode of entrance of the specific organism of yellow 
fever into the body has not been determined. It has not been 
isolated from the bowel or from the black vomit. Intraven- 
ous inoculation of living or dead cultures into dogs causes in- 
fection in from a few hours to twenty-one days. Symptoms 
of diarrhea, anuria, loss of weight, and jaundice were noted. 
Nephritis, fatty degeneration of the liver, and hyperemia of 
the intestinal walls were found upon postmortem examination. 
Inoculations into man give rise to symptoms of yellow fever, 
as stated by Sanarelli. The agglutination test can be per- 
formed by mixing the serum of yellow-fever patients with the 
bacillus icteroides in the dilution of about 1 : 40. Immunized 
serum gives promise of favorable results as a prophylactic and 
curative agent. 

Micrococcus Melitensis. — This micrococcus was ob- 
tained from the spleen in cases of Malta fever, by Bruce. The 
organism is oval or rounded, and measures -^ of a micron in 
diameter. It grows singly, in pairs, and sometimes in short 
chains. It stains with the ordinary anilin dyes and decolorizes 
by Gram's method. 

Biologic Characteristics. — It is aerobic, nonmotile,and does 
not liquefy gelatin. It is said to possess flagella. Upon agar 
slants colonies will be visible about the third day. As the 
growth becomes older it changes to a pearly-white color. It 
may be cultivated in bouillon. Growth is not visible upon 
potato media. The agglutination test has been observed by 
mixing the serum of patients suffering from Malta fever with 
the micrococcus melitensis. 

Actinomyces (Ray Fungus).— This micro-organism belongs 
to a higher group than the bacteria. It produces a disease 
known as actinomycosis, which is common in animals but also 
affects man. It has been found in various organs of the body. 



122 LABORATORY METHODS. 

The tissue lesions consist of granulation tumors and often the 
production of suppuration, the micro-organism being contained 
in the pus. It first appears as filaments of great length, and 
about t 5 q- of a micron in diameter. In colonies these filaments 
present an irregular network arranged in a somewhat radiating 
manner, and some of the filaments show branching. The 
actinomyces, when seen growing upon culture-media, reveals 
filaments growing upward, the protoplasm of which becomes 
segmented into spores. These spores, when they become free, 
may again give rise to the growth. At the periphery of the 
colonies there are also seen pear-shaped bodies that are 
formed by swelling of the sheath around the extremity of the 
filament. When stained by Gram's method, the filaments and 
the spheric bodies retain the stain, while the club-shaped bodies 
are not colored. The pear-shaped bodies are sometimes absent 
in the colonies. Outside the body the parasite is said to grow 
upon certain forms of grain, such as barley, the infection being 
conveyed in this manner. It may be cultivated upon agar at 
the temperature of 37 ° C, colonies appearing about the fourth 
day, which are circular in outline, of a reddish-yellow color, 
and somewhat raised ; the media surrounding may be colored a 
brownish tint. Older cultures present a somewhat corrugated 
aspect. The organism may be cultivated under anaerobic con- 
ditions. It slowly liquefies gelatin, and may be cultivated upon 
potato. 



LABORATORY METHODS. 

EXAMINATION OF THE SPUTUM. 

The sputum consists of those substances which are ex- 
pectorated either by the efforts of coughing or hawking. It 
results from various diseases of the respiratory tract ; practi- 
cally all diseases of this tract are accompanied by coughing 
and expectoration. When coughing is attended by expectora- 
tion, it is called productive ; and when unattended by expec- 
toration, it is spoken of as unproductive. In children, in the 
aged, and in the insane, expectoration is sometimes not noticed, 
as in these cases it is often swallowed. The examination of 
the sputum should be carried on by means of macroscopic and 
of microscopic methods. 

Macroscopic Examination. — Under this heading will be 



EXAMINATION OF THE SPUTUM. I 23 

considered the quantity, the form or consistence, the color, 
the reaction, and the specific gravity. 

The Quantity of Sputum. — The quantity of sputum varies 
greatly, depending upon the pathologic lesions. It is scanty 
or even absent in the early stages of acute bronchitis, croup- 
ous pneumonia, miliary tuberculosis of the lungs, and in the 
first stages of asthma. It is more profuse in cases of acute 
bronchitis which have lasted for several days, also after croup- 
ous pneumonia has existed for some time ; in well-marked 
caseous tuberculosis with cavity formation, abscess of the 
lung, and bronchiectasis. It may be profuse in caseous 
tuberculosis, chronic bronchitis (bronchorrhea), and in empy- 
ema that communicates with a bronchus. In many cases 
the sputum is apt to be more profuse in the early morning 
and at night ; this is particularly true of chronic tuberculosis. 
Again, the quantity may be profuse at certain periods of the 
day, as in bronchiectasis or in cavity formation. 

Form or Consistence. — Serous Sputum. — In this form the 
character of the expectoration is watery, and consists largely 
of serum. It occurs in edema of the lungs with or without 
inflammatory lesions. In this variety of sputum albumin is 
present in large amounts, and the material is often frothy. 

Mucous Sputum. — This occurs as the result of catarrhal 
inflammation of the respiratory tract. It has a glassy, trans- 
parent appearance, the consistence varying somewhat, depend- 
ing upon the amount of saliva mixed. 

Mucopurulent Sputum. — This is the most common form of 
sputum, and consists of a mixture of mucus and pus. It 
is usually translucent, yellowish or greenish in color, and 
may appear in flakes or in flattened masses circular in outline, 
called nummular or coin-shaped sputum. It is common in 
the later stages of inflammation of the mucous membrane of 
the respiratory tract, in tuberculosis, particularly when cavity 
formation is present. In the latter condition it is apt to be 
nummular, and is sometimes spoken of as cavernous sputum. 
Mucopurulent sputum may occur in bronchiectasis. On allow- 
ing it to stand it often separates into three layers : an upper 
frothy layer ; a middle purulent, slimy, and watery layer ; and a 
lower layer consisting of pus or granular material. 

Purulent Sputum. — This form of sputum, as the name indi- 
cates, is composed almost entirely of pus. It is present in 
empyema communicating with the bronchus, in abscess of 
the lung, and in some forms of bronchitis, also in abscess of the 



124 LABORATORY METHODS. * 

liver when this communicates with the bronchus, or in sub- 
phrenic abscess existing under similar conditions. This sputum 
varies in consistence ; most commonly, however, it is quite 
thick. It has a peculiar, sour smell, not unlike buttermilk. 
The odor may be very offensive, especially when decompo- 
sition sets in. When allowed to stand, it separates into two 
layers — the lower one being made up chiefly of pus-corpuscles, 
the upper one being fluid, due to pus plasma. Should the 
sputum be very frothy, a third layer may be noted upon the 
top, consisting of frothy material. 

Bloody Sputum. — This sputum may consist entirely of pure 
blood, it may be blood-tinged, or the sputum may be intimately 
admixed with blood. It is usually large in amount, has a 
bright red color, shows its watery character, and may be frothy. 
It most frequently occurs in tuberculosis of the lungs, appear- 
ing early or late with cavity formation. It is also met with in 
abscess and gangrene of the lung, infarction, trauma, croupous 
pneumonia, rarely in bronchiectasis, rarely in putrid bronchitis 
(from excessive coughing), tumors and aneurysms communicat- 
ing with the bronchus and echinococcus, also in blood dys- 
crasias, such as purpura haemorrhagica, and hemophilia, and it 
may occur in vicarious menstruation. Blood-tinged sputum 
may appear as the result of any of the conditions just enumer- 
ated, and sometimes follows copious expectoration of blood, 
this being due to a certain amount of blood that is retained 
in the air-passages. Blood-tinged sputum may also result 
from croupous pneumonia. It is of two characters — the first 
being known as rusty sputum, being very tenacious ; and the 
second, " prune-juice " sputum, which is viscid and fluid, the 
color corresponding to prune juice, hence the name. It may 
appear in hemorrhagic infarcts, mitral disease, and in miliary 
tuberculosis. It is occasionally found in acute bronchitis, 
particularly in plethoric subjects. 

Color of the Sputum. — This may vary, depending upon the 
cause. It may be translucent and almost colorless, or light 
yellow, such as occurs in chronic bronchitis. It may be of a 
deep yellow color when it is bile-stained, occurring in jaundice ; 
or it may be red when containing blood or iron ; or blackish 
gray, as a result of anthracosis. In some instances it is green, 
as a result of admixture of pus, particularly when the bacillus 
pyocyaneus is present. 

Reaction. — The reaction of sputum is always alkaline. 

Specific Gravity. — The specific gravity is from 1004 to 



EXAMINATION OF THE SPUTUM. 



12! 



1026. Neither of the last two characteristics mentioned are of 
special diagnostic import. 

Microscopic Examination of the Sputum. — Fibrinous 

casts of the bronchi are sometimes present in the sputum, and 
occur as a result of fibrinous or plastic bronchitis. They 
appear in the sputum as small 
spheric masses, and when placed 
in water, separate after being 
teased out into twig-like bodies. 
They are made up of fibrin, epi- 
thelial cells, some leukocytes, and 
even micro-organisms. 

Spiral bodies are sometimes 
observed in the sputum. They 
were described by Curschmann 
and Leyden, and are known as 
Curschmann's spirals. They occur 
in asthma, bronchial catarrh, and 
fibrinous pneumonia. They vary 
in length and diameter, often be- 
ing visible to the naked eye. They 

are frequently covered by epithelial cells and Charcot-Leyden 
crystals. They are composed of a substance resembling mucin. 




Fig. 18. — Fibrinous bronchial cast. 




Fig. 19. — Sputum from a case of asthma, showing Curschmann spirals, Charcot-Leyden 
crystals, leukocytes, and numerous free eosinophile granules ; unstained specimen (Jakob.) 



Dittrich's plug occurs in putrid bronchitis and gangrene of 
the lungs. These vary in size from that of a pinhead to that of a 
bean, being composed of fatty acids, fat corpuscles, round cells, 



126 LABORATORY METHODS. 

red blood-cells, hematoidin, and micro-organisms. Small, gel- 
atinous, round masses are met with in the sputum of bronchial 
asthma, and are known as the perles of Laennec. Elastic 
fibers occur, particularly in tuberculosis, abscess, and gangrene 
of the lung. They vary in length and breadth, are usually 
curved, and are somewhat flattened. They are indicative of 
the destruction of lung-tissue. They frequently show an 
alveolar arrangement, and epithelial cells may be found ad- 
hering to these structures. They are only of diagnostic import 
when they conform to an alveolar arrangement. They may 
be detected by the following method : The sputum is mixed 
with a solution of caustic potash (8</o to io^>), this is brought 
to the boiling-point, and then allowed to stand for twenty-four 
hours in a conical glass, when the sediment can be examined 
microscopically. Various other particles may be present in 
the sputum, such as fragments of cartilage, connective-tissue 
masses, or small portions of tumors (sarcoma and carcinoma). 

Crystals. — CHareot-Leyden Crystals. — These vary in size, 
are elongated octahedrals, and of a transparent bluish color. 
They are easily visible with the low powers of 'the microscope. 
They are met with in asthma, sometimes in tuberculosis, 
croupous and acute bronchitis. 

Cholesterin Crystals. — These appear as large, sometimes ir- 
regular, rhombic plates, showing a tendency to group. When 
treated with sulphuric acid, they become yellow and finally 
green ; or with diluted sulphuric acid and tincture of iodin, a 
violet color is produced, which later changes to blue, green, 
and red. They are of little significance and have been met 
with in tuberculosis and abscess of the lung. 

Hematoidin Crystals. — These have been found in the sputum 
as rhombic prisms or as needles, frequently in clusters. When 
these crystals are present, they are often indicative of recent 
hemorrhage. Fat crystals are encountered in putrid bron- 
chitis and gangrene. 

Triple Phosphate Crystals. — Triple phosphates are some- 
times encountered in the sputum. 

White Blood=corpuscles. — These are always present in the 
sputum, and large amounts are indicative of inflammatory 
conditions. The polynuclear eosinophiles are present in large 
numbers in asthma. 

Red Blood=corpuscles. — These are also usually present in 
small numbers. When occurring in considerable quantity, 
they are indicative of hemorrhage or acute inflammatory con- 



EXAMINATION OF THE SPUTUM. \2J 

ditions. The blood-cells may be only slightly altered (cre- 
nated), or washed out (phantom or shadow corpuscles). 

Epithelial Cells. — Sputum always contains some epithelium. 
When occurring in large numbers, this is indicative of path- 
ologic changes, such as catarrhal inflammation, tuberculosis, 
etc. It may be squamous, columnar, or ciliated. Large, flat 
epithelial cells may arise from the alveoli. It must be remem- 
bered that under pathologic conditions epithelium may undergo 
alteration, especially as to shape ; particularly is this so in 
bronchiectasis. The epithelial cells frequently reveal degen- 
erative changes, so that the nucleus is with difficulty differen- 
tiated. % 

Micro=organisms. — Many micro-organisms are encountered 
in the sputum, and it may be said that the sputum always 
contains them when it is admixed with saliva. 

The Bacillus of Tuberculosis. — This micro-organism is of 
great diagnostic import when found in the sputum, and is always 
indicative of tuberculosis. The material for examination is 
placed upon a glass plate, and then selecting the small cheesy 
masses contained therein, are placed upon a slide or cover-glass, 
spread out and gently dried over a flame ; the material is then 
fixed by rapidly drawing the cover-glass through the flame 
three times. (For method of staining the tubercle bacillus, 
see p. 105.) 

The Diplococcus of Pneumonia. — This micro-organism is 
found in the sputum in the greater number of cases of croup- 
ous pneumonia, and often in normal saliva. (For method of 
detection, see p. 103.) 

The Bacillus of Influenza. — The bacillus of influenza is 
found in cases suffering from influenza. (For method of detec- 
tion, see p. 118.) 

The Bacillus of Diphtheria, — The bacillus of diphtheria 
may be present in the sputum of cases suffering from diph- 
theria. (For method of detection, see p. ill.) 

The Bacillus of Friedlander. — The bacillus of Friedlander 
may be found in the sputum of some cases of croupous pneu- 
monia. (For method of detection, see p. 104.) 

The Ray Fungus. — The ray fungus is sometimes present 
in the sputum. (For method of detection, see p. 121.) 

Animal parasites are sometimes present in the sputum, 
such as the echinococcus, the distoma pulmonale, and in- 
fusoria. 



125 LABORATORY METHODS. 

EXAMINATION OF THE STOMACH-CONTENTS. 

The most important chemic constituents found in the gastric 
contents are pepsin, rennet or milk-curdling ferments, inor- 
ganic and organic acids. Before making a careful examina- 
tion of the stomach-contents it is necessary to give a test- 
meal. This should be given upon an empty stomach ; it is 
best, therefore, to administer the meal in the morning or after 
washing out this organ. Ewald's test-meal, the one most gen- 
erally employed, consists of two cups of tea, without sugar and 
milk, or 300 c.c. of water, and 70 grams of dry wheat bread. 
The bread should be thoroughly masticated. The stomach-con- 
tents are withdrawn one hour after ingestion, at which time the 
maximum secretion of hydrochloric acid is obtained under 
normal conditions. This meal sometimes exerts very little 
stimulation to the stomach, particularly the secretion of gastric 
juice, and for this reason a test-meal of meat and starches has 
been suggested. Leube's test-meal consists of a plate of water 
soup, a small amount of beefsteak, and wheat bread. This test- 
meal is withdrawn from four to five hours after ingestion. 

Method of Evacuating the Stomach. — Soft stomach- 
tubes are used for this purpose, the best being the Ewald, 
Leube, and Jaques. A mark appears upon the tube indicating 
the distance it should be introduced, which is from eighteen to 
twenty-two inches from the incisors. Before introducing the 
tube it should always be moistened with water, glycerin, or oil. 

Method of Introducing the Tube. — The patient prefer- 
ably should assume the sitting posture, and raise the head a 
little. The operator standing behind or to the right or left of 
the patient, grasps the tube in the right hand. The patient 
opening the mouth wide the tube is introduced until it reaches 
the end of the tongue ; it is then rapidly but gently pushed 
downward, until the proper depth has been reached, the opera- 
tor at the same time asking the patient to swallow. The first 
operation is usually attended with vomiting, excitement, dis- 
turbed breathing, and some cyanosis. These may be so great 
that the operation must be suspended. If the manceuver be 
repeated a number of times, the patient is usually able to in- 
troduce the tube himself. After the tube is inserted the con- 
tents may spurt out of it, or in other instances it is necessary 
to make compression in the region of the abdomen correspond- 
ing to the stomach, or have the patient bend forward. The 
stomach-pump may be employed, or the material may be 



EXAMINATION OF THE STOMACH-CONTENTS. 1 29 

siphoned by allowing a quantity of water to flow into the 
tube, and lowered while it is well filled with fluid. The 
contraindications to the use of the stomach-tube are severe 
hemorrhages from the stomach, and aneurysms. If great de- 
bility exists, it is sometimes better to strenghten the patient 
before performing the operation. 

Gross Appearance of the Stomach- contents. — The con- 
tents should be carefully examined, the various solid particles 
noted, such as articles of food, pieces of tissue from the 
stomach-wall, bile, pus, blood, fragments of tumors, etc. 
Microscopic examination will determine the presence of pus, 
blood, or epithelial cells ; the latter, if occurring in masses, 
presenting an irregular or atypical arrangement, strongly indi- 
cate carcinoma. Other solid particles that have been ingested 
may also be determined by microscopic examination ; also 
micro-organisms, such as sarcinae, fungi, and various bacteria. 
The Oppler-Boas bacillus is often found in cases of carcinoma 
of the stomach, particularly when lactic acid is present. The 
capacity of the normal stomach is about 1700 c.c. 

Chemic Examination of the Stomach- contents. — After 
the Ewald test-meal has remained in the stomach for an hour 
it is withdrawn by the soft rubber stomach-tube in the manner 
previously described. About thirty cubic centimeters of the 
semidigested material is filtered and subjected to chemic ex- 
amination ; the following tests are of the most importance : 
The reaction, the total acidity, the presence of free hydro- 
chloric acid, of lactic acid, of butyric acid, and of acetic acid. 
It is sometimes important to estimate the quantity of hydro- 
chloric and lactic acids. The test for pepsin and rennet is 
also sometimes important. 

Reaction. — Under normal circumstances the reaction of the 
material for examination is determined with litmus paper. 
Free acids, both organic and inorganic, may be tested with 
Congo-red paper, a blue color being noted if they are pres- 
ent. 

Total Acidity. — This test is performed in the following way : 
Ten cubic centimeters of the filtered fluid are treated with 
a decinormal solution of caustic soda (4 grams of caustic soda 
to 1000 grams of water), using phenolphthalein as the indi- 
cator. Under normal conditions it requires from 50 to 65 c.c. 
of a decinormal solution of soda to neutralize 100 c.c. of fil- 
tered stomach-contents, the material being withdrawn one hour 
after the ingestion of Ewald's test-meal. 
9 



I30 LABORATORY METHODS. 

Tests for Free Hydrochloric Acid. — Gunzburg's Test. — The 
reagent necessary to perform this test is the following : Phlo- 
roglucin, 2 grams ; vanillin, 1 gram ; and alcohol, 30 c.c. A few 
drops of the filtered stomach-contents are placed in a porcelain 
dish, and are mixed with the same amount of the reagent ; if free 
hydrochloric acid be present, a rose-red color is developed. 
This test is quite delicate. Von Jaksch detected 0.00 1 mgrm. 
of acid in 10 c.c. of gastric juices. 

Boas' Test. — The reagent necessary for this test is the fol- 
lowing : Resorcin, 5 grams ; cane-sugar, 3 grams ; and weak 
alcohol, 100 c.c. A few drops of the filtered stomach-contents 
are placed in a porcelain dish, mixed with a few drops of the 
reagent, and evaporated to dryness. If free hydrochloric acid 
be present, a red color is developed ; upon cooling the color 
disappears. 

Benzopurpurin Test. — Test-papers are prepared by soaking 
filter-paper in a watery solution of benzopurpurin, and then 
allowing them to dry. On the addition of free hydrochloric 
acid the color changes to a dark red. Acetic, formic, and lactic 
acids give a similar reaction ; the color, however, being 
brownish violet. 

Tropeolin Test. — Test-papers may be prepared by soaking 
filter-paper in a solution of tropeolin, and on the addition of 
hydrochloric acid a dark-brown color is produced. This test 
also responds to free lactic acid. 

Lactic Acid. — Uffelmann 's Test. — To a mixture of 20 c.c. 
of water and 10 c.c. of 4^ watery solution of carbolic acid is 
added one drop of the tincture of the perchlorid of iron ; an 
amethyst-blue color is developed. On the addition to this mix- 
ture of filtered stomach-contents that contain lactic acid, a 
canary-yellow color is noted. The delicacy of this test is 
hindered by phosphates, alcohol, glucose, and hydrochloric 
acid. 

Boas' Test. — To about 20 c.c. of filtered stomach-contents 
add carbonate of barium,— in excess if the reaction of the fluid 
for examination be acid, and evaporate the mixture to a syrupy 
consistency ; then add a few drops of phosphoric acid, heat the 
fluid so as to drive off the carbonic acid, allow the substance 
to cool, and pour 100 c.c. of ether (alcohol free) into it ; shake 
the mixture, then allow it to stand for half an hour, when the 
ether is poured off and evaporated to dryness, the residue 
being dissolved in 45 c.c. of water and filtered. The fluid is 
poured into a Florence flask, a little manganese and 5 c.c. of 



EXAMINATION OF THE STOMACH-CONTENTS. 1 3 I 

sulphuric acid added. A glass tube is used to connect the 
flask with a cylinder containing about 10 c.c. of an alkaline 
iodin solution (equal parts of a decinormal iodin solution and 
a decinormal solution of sodium). Upon heating the flask 
iodoform is formed in the iodin solution, which is detected by 
its odor and color. 

Butyric Acid. — This substance may be determined by 
Uffelmann's test. A turbid brown color is produced when 
butyric acid is present, and a rancid smell is detected. 

Acetic Acid. — This is detected by the following test : Ex- 
tract some of the filtrate with ether, evaporate to dryness, and 
dissolve the residue in water. This solution is then neutral- 
ized with a decinormal soda solution, and on the addition of 
the tincture of perchlorid of iron a red color is developed, if 
acetate of sodium be present. 

Quantitative Test for Free Hydrochloric Acid. — Mints 's 
Method. — If a solution of soda be added to inorganic and 
organic acids, it will be noted that the former is neutralized 
before the latter. The method is as follows : To 10 c.c. of 
the filtered stomach-contents a decinormal solution of soda is 
slowly added, testing the mixture from time to time by placing 
a few drops upon a porcelain plate and subjecting this to the 
phloroglucin vanillin test. The alkali is added to the filtrate 
until the hydrochloric acid is neutralized, this being deter- 
mined when the mixture ceases to give the reaction with 
Giinzburg's test. Note the number of cubic centimeters of 
decinormal solution of soda used and multiply this number by 
0.00365 gram, the result being the amount of hydrochloric 
acid (expressed in grams) present in 10 c.c. of stomach- 
contents. 

Quantitative Test for Lactic Acid. — After boiling 10 c.c. 
of filtered stomach-contents a few drops of sulphuric acid are 
added in order to coagulate the albumin ; the solution is then 
filtered and evaporated to a syrupy consistency ; to this are 
added 10 c.c. of distilled water, and the mixture evaporated to 
dryness ; to the residue ether is added, the ethereal solution 
separated and evaporated ; the remaining solid portion is dis- 
solved in water and neutralized with a decinormal soda solu- 
tion One cubic centimeter of soda solution is found to corre- 
spond to 0.009 g ram of lactic acid. To complete the test, 
the number of cubic centimeters of soda solution used is 
multiplied by 0.009, tne resu h being the amount of lactic 
acid present in 10 c.c. of the stomach-contents. 



132 LABORATORY METHODS. 

Test for Pepsin. — This test depends upon the property of 
pepsin changing fibrin into peptone. To 20 c.c. of filtered 
stomach-contents is added a small amount of hydrochloric 
acid, if the fluid is not acid in reaction. A small quantity of 
washed-out blood fibrin is placed into the fluid for examina- 
tion and set aside in a warm place (40 ° C.) for a number of 
hours, and if pepsin be present, the fibrin will become dissolved ; 
if after ten or twelve hours this does not occur, it may be 
inferred that the substance is not present. From the rapidity 
of solution the approximate amount of pepsin may be deter- 
mined. 

Rennet. — To indicate the presence of this ferment 10 c.c. 
of the filtrate are neutralized. To this is added an equal vol- 
ume of sterile milk ; after an exposure for twenty or thirty min- 
utes at a temperature of from 30 to 40 C, coagulation will 
ensue if rennet be present. 

Rate of Absorption of the Stomach. — This may be deter- 
mined by administering a capsule containing o. I gram of po- 
tassium iodid, and after a short time testing the saliva with 
starch paper every two or three minutes ; when iodin is pres- 
ent in the saliva, the moistened starch paper will assume a blue 
color on the addition of nitric acid. Under normal conditions 
this reaction appears in from eight to fifteen minutes after the 
capsule is swallowed. 

The activity or motor power of the stomach is deter- 
mined by administering a capsule of one gram of salol, this 
being decomposed into salicylic acid and phenol in the small in- 
testine, where absorption takes place, salicyluric acid soon after 
appearing in the urine. This is demonstrated by the addition 
of a solution of perchlorid of iron to the urine, a violet color 
developing. Under normal conditions it requires from forty to 
sixty minutes for the stomach to expel its contents into the 
small intestine. 

The Vomit. — The quantity and frequency of the vomit de- 
pend upon the amount of food ingested, and the pathologic 
lesions, such as gastritis, gastro-enteritis, peritonitis, tumors, 
some of the infectious diseases, uremia, diseases of the brain, 
and pregnancy. The character of the material vomited de- 
pends upon the food ingested and the degree of digestion, 
whether it be mixed with bile, pus, blood, or mucus. 

Mucous vomit is encountered in chronic gastritis, nervous 
dyspepsia, and the dyspepsia resulting from a healed gastric 
ulcer. 



EXAMINATION OF THE BLOOD. 1 33 

A serous vomit occurs in Asiatic cholera (rice-water vomit). 

Bile=stained vomit is due to the mixture of bile with the 
stomach-contents, and occurs from obstruction of the bowels, 
peritonitis, and sometimes from violent vomiting spells. 

Blood Vomiting (Hematemesis). — This is due to conges- 
tion of the stomach, such as is encountered from portal 
obstruction, from hyperemia, and from inflammation ; occa- 
sionally, blood is swallowed and then vomited. It is met 
with in yellow fever, in the hemorrhagic diathesis, in melena 
neonatorum, in rupture of an aneurysm, in ulceration of the 
stomach-wall, as in gastric ulcer and carcinoma, in vicarious 
menstruation, and in trauma. 

Pus. — The vomiting of pus is observed when an abscess 
perforates into the stomach, or in exceedingly rare instances 
from phlegmonous gastritis. 

Fecal Vomiting. — This is encountered in general peritoni- 
tis, and from obstruction of the bowels. 

Animal parasites are sometimes encountered in the vomit, 
such as the oxyuris vermicularis, the anchylostoma duodenale, 
the trichina and echinococcous hooklets. 



EXAMINATION OF THE BLOOD. 

The blood is often of great importance in diagnosis ; as it is 
a fluid tissue bearing a relation to other tissues, it reflects 
morbid conditions of distant parts. During the last few years 
methods of examining the blood have been improved, and this 
has lent additional accuracy to diagnosis in many important 
diseases. For all practical clinical purposes the examination 
of the blood consists of a macroscopic, a microscopic, and in 
some rare instances of a special chemic examination. 

Method of Procuring the Blood. — Certain precautions are 
necessary in procuring the blood. For the purposes of ordi- 
nary examination the superficial blood is selected. It is rarely 
justifiable to secure the blood from an internal organ, such as 
the spleen. The lobe of the ear or the finger-tips are usually 
the points chosen. The former site is preferable since the 
skin is not so sensitive, is thinner, and the part more flexible ; 
the manceuver can often be performed without the patient 
observing the operation. In hysteric women the lobe of the 



134 LABORATORY METHODS. 

ear should always be selected. Before making the puncture 
it is safer to inquire whether the patient is a bleeder, for 
if this is the case, the wound should be made with great 
precaution, and be very superficial, the' operator having meas- 
ures at hand to control the flow of blood. Great care must be 
taken not to select a part of the body that is edematous, for 
under such a condition the serum in the lymph-spaces gives 
rise to fallacies, such as dilution. It is also important to 
select a part where the circulation is good, the part being 
warmed by friction ; inflamed areas should be avoided. Or- 
dinary cleansers — soap and water — are all that are necessary 
in the preparation of the part, and attempts at careful steriliza- 
tion are unnecessary. If the hand is selected for the site of 
puncture, it is advisable under ordinary circumstances to select 
the left hand if the patient is right-handed, or vice versa. 
While septic infection has never been recorded from puncture 
in this manner, it requires no extra labor to use this precau- 
tion. If the skin is cold, rubbing so as to excite hyperemia 
is recommended by most authorities. A deep thrust, going 
into the skin y% of an inch or slightly more is usually suffi- 
cient. The needle should have a cutting edge, such as the 
two- or three-sided surgical needle, or a steel pen or sharp 
instrument may be employed for this purpose. The first few 
drops should not be utilized for examination, but these 
may simply be wiped away. The part must not be squeezed, 
as by this procedure the serum will escape before the cor- 
puscles. 

Macroscopic Appearance of the Blood. — Color. — The 
color of the blood should be carefully noted. Blood, pro- 
cured by puncture as just indicated, in the normal individual 
is bright red. If taken directly from an artery, it is of a 
brighter red color than when taken from a vein, the latter 
being bluish-red, the arterial blood containing more oxygen. 
In severe anemias the shade of the blood is found to be much 
lighter, and presents a serous character. In pernicious 
anemia it is frequently brownish-red in color, resembling thin 
coffee. It is dark red or bluish-red from cyanosis and during 
a chill. From poisoning by potassium chlorate, nitrobenzol, 
or amyl nitrite it is brownish-red. From coal-gas poisoning 
it is a scarlet-red color. In leukemia the blood often has a 
milky or pus-like appearance, and in lipemia it may have a 
similar appearance. 

For determining the color of the blood it should be placed 



EXAMINATION OF THE BLOOD. 1 35 

upon a clean sheet of white paper and compared with normal 
blood. 

Coagulability and Fluidity. — According to Vierordt, nor- 
mal blood will coagulate in 9.28 minutes. The coagulability 
is increased after the administration of calcium chlorid and 
carbonic acid ; also in some diseases, such as tuberculosis of 
the lungs, scurvy, and leukemia. It is decreased after the 
administration of citric acid and alcohol, and after increased 
respiratory efforts. In the acute exanthematous diseases and 
in the hemorrhagic diathesis it is also decreased ; this is par- 
ticularly true of hemophilia, it often requiring from thirty to 
fifty minutes for coagulation to take place in this condition. 

Specific Gravity. — The specific gravity of normal blood is 
about 1059. The degree of specific gravity and the amount 
of hemoglobin seem to bear a distinct relation to each other, 
so that a decrease in specific gravity indicates a decrease in 
hemoglobin. 

Hammerschlag's investigations x have proven that there is 
a much closer relationship between the specific gravity and 
the hemoglobin than between the specific gravity and the 
number of erythrocytes. The following table, based on many 
repeated examinations, has been found almost constant : 



Specific Gravity. 


Hemoglobin {after Fleischl) 


1033 to 1035 


25 to 30% 


1035 " 1038 


30 "35% 


1038 " 1040 


35 "40% 


1040 " 1045 


40 "45% 


1045 " 1048 


45 "55% 


1048 " 1050 


55 "65% 


1050 " 1053 


65 » 70% 


1053 " 1055 


70 "75% 


1055 " 1057 


75 "85% 


1057 " 1060 


85 "95% 



Method of Determining the Specific Gravity. — - Hammer- 

schlag's modification of Rofs method is best suited for clinical 
purposes. It is based on the principle that a drop of blood is 
suspended in a liquid having the same specific gravity. Chloro- 
form is heavier than blood and benzol is lighter, and when a 
mixture of these two liquids is obtained corresponding to the 
specific gravity of normal blood the latter will be suspended 
in the mixture. If the blood is lighter than the mixture, it 
will float ; some benzol should be added until it is suspended. 
If it is heavier, some chloroform should be added. The 

1 "Centralbl. f. klin. Medicin," 1891, No. 44. 



136 



LABORATORY METHODS. 



specific gravity of the mixture is then determined by the ordi- 
nary urinometer. Care should be taken to prevent air from 
gaining access to the drop of blood. 

Alkalinity. — Normal blood is always alkaline in reaction. 
No practical method for determining the degree of alkalinity 
of the blood has yet been devised. 

Estimation of Hemoglobin. — Under normal conditions the 
hemoglobin is contained in the red blood-cells as an albumin- 




Fig. 20.— Von Fleischl'shemoglobinometer : a, Stand; 5, narrow wedge-shaped piece 
of colored glass fitted into a frame (c), which passes under the chamber ; d, hollow metal 
cylinder, divided into two compartments, which holds the blood and water ; e, white plate 
from which the light is reflected through the chamber ; f, screw by which the frame con- 
taining the colored glass is moved ; g-, capillary tube to collect the blood ; k, pipet for 
adding the water ; i, opening through which may be seen the scale indicating percentage 
of hemoglobin. 



ate, which is soluble in water. For methods of determining 
the amount color tests are employed by comparing the blood 
with a color scale. 

Von Fleischl's Hemoglobinometer. — The principle of this 
apparatus is based upon the fact that a mixture of blood and 



EXAMINATION OF THE BLOOD. 1 37 

water is compared with a graduated color scale, this being a 
wedge-shaped tinted piece of glass. The intensity of the color 
scale corresponds to certain percentages. A pipet for meas- 
uring the quantity of blood is used that is supplied with the 
apparatus. When this is filled with normal blood and mixed 
with a certain quantity of water, as will be described below, 
the intensity of the color should correspond to the color in 
the tinted wedge marked iooft . The cylinder in which the 
blood is mixed is divided into two compartments — one con- 
taining the mixture of blood ; the other, distilled or pure 
water. T.his receptacle is then placed upon the stage of the 
instrument, the wedge-shaped tinted glass being directly under 
the half of the cylinder that is filled with water. A plaster-of- 
Paris reflector is used to reflect the light. The estimation 
must always be performed in a dark place, yellow light only 
being used for illumination, as from a candle. 

A box may be constructed so that all but the adjustment 
of the instrument is in a dark space, artificial light being used 
for illumination. In matching the colors it is best to first 
move the thumb-screw to the light or the dark shade of the 
red, and then match the colors, the percentage being noted. 
This manceuver is repeated, starting from the opposite side of 
the color scale, the percentage again being noted. The aver- 
age of the two readings should be the result. There is 
always a certain liability to error, so that the result is not 
absolutely accurate. Some individuals have difficulty in 
matching the colors. It is to be remembered that we must 
match the central portion of the color scale, one of its ends 
in view being lighter and the other darker. By using a shield 
that allows only a small portion of the central part to be in 
view error is almost avoided. When the percentage of hemo- 
globin is under 20, the reading is difficult and unreliable, so 
that in this case it is best to use two pipets filled with blood 
and divide the result by 2. 

Oliver's Hemoglobinometer. — This instrument is also 
based upon a color comparison, except that it differs from the 
Fleischl instrument inasmuch that reflected light is used instead 
of transmitted light, also that in its percentage determination 
twelve tinted discs are used instead of a wedge-shaped tinted 
glass. These tinted discs are graduated so that they corre- 
spond to the number scale 1 o ft , 20 ft , 30 ft , 40 ft) , 50 ft , 60 ft , 
70 ft ,80 %, go ft , \ooft,iioft,i2oft. The blood is measured 
in a pipet similar to that used in the Fleischl apparatus, except 



138 



LABORATORY METHODS. 



that it is much stronger and more easily handled and cleansed. 
The blood is then washed into the mixing cell and covered with 
a glass plate. Two forms of instruments are made, one to be 
used with candle-light, the other with daylight, the former 
being the more accurate. In order to estimate the percentage 
of hemoglobin more accurately — that is, so as to get the per- 
centage nearer than 10 points — colored glass plates called 
" riders " are used, being placed upon the primary discs, which 
intensify the shade of the color. The error in this instrument 
is about 2 <f • 

Gower's Hemoglobinometer. — This instrument is based 
upon a color comparison, the blood being diluted with water 



^\ 





Fig. 21. — Dare's hemoglobinometer. 



until it corresponds to a color standard. The amount of 
fluid required to dilute it equals a certain percentage. One 
hundred grams of normal blood contains 14 grams of oxy- 
hemoglobin. 

Dare's Hemoglobinometer. — This instrument (Fig. 21) is 
also based upon a color comparison. A tinted glass is com- 
pared with a definite thin film of blood (not diluted with 
water), candle-light being used for illumination. 



EXAMINATION OF THE BLOOD. 



139 



Estimation of the Red Corpuscles. — Method of Counting 
the Blood=corpuscles by Means of the Thoma=Zeiss Appa- 
ratus. — This apparatus consists of a glass pipet containing a 




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Fig. 22.— Thoma-Zeiss blood-counting apparatus. 1. Mixing apparatus : a, Capillary 
tube in which the blood is taken ; b, chamber for mixing the blood with the diluting solu- 
tion ; c, glass ball to aid in mixing the blood with the diluting solution. 2. Cross-section 
of the chamber in which the blood is counted. 3. Section of the field on which the blood 
is counted, showing thirty-six squares. 



capillary tube expanding into a bulb in which lies a glass ball ; 
the bulb is then contracted and again merges into a small 



I40 * LABORATORY METHODS. 

capillary portion. The lower end of the capillary bore is 
graduated into 10 parts — from -^ to 1. The capillary portion 
above the bulb is marked 101. 

By filling the pipet with blood up to the point i, and then 
with some diluting solution up to the point 101, a solution of 
1 : 100 is obtained. By filling the pipet up to the point -j^-, 
and the diluting solution up to the point 101, a solution of 
1 : 200 is obtained. The other part of the instrument is the 
counting chamber. This consists of a thick glass slide upon 
which is cemented a disc, upon the surface of which are a 
number of rulings dividing it into 400 squares, each of these 
squares measuring -^ of a millimeter in length and the same 
in breadth. Around this disc there is a depression formed by 
a hollowed cover-glass cemented upon the slide. This glass 
plate is y 1 ^ of a millimeter thicker than the disc. When a 
cover-glass is placed upon the counting chamber, the space 
overlying each square is ^qVo °f a CUD i c millimeter. Double 
rulings are also found upon the disc, these being so arranged 
as to indicate or outline 16 squares. Certain solutions are 
recommended for diluting the blood. Toisson's solution gives 
very good results ; it is of special value, as it stains the white 
corpuscles a violet or blue color. 

The formula is as follows : 

Methyl-violet, 5 B 0.025 gm. 

Chlorid of sodium 1. 000 " 

Sulphate of sodium 8.000 " 

Neutral glycerin . . , 30.000 c.c. 

Distilled water 160.000 " 

Gowers' diluting fluid also gives good results, the formula 
being as follows : 

Sulphate of sodium gr. cxij 

Acetic acid % v 

Water , %' lw - 

A2^ solution of bichromate of potassium is strongly 
recommended by some authorities, and gives excellent results. 
A 3 f sodium chlorid solution may also be employed for the 
same purpose. 

Method of Procedure. — The pipet must be perfectly clean. 
The usual precautions of obtaining the blood are to be ob- 
served. The blood is now sucked into the pipet up to the 
point of y^- or I . When great anemia exists, it is always best 
to fill the pipet up to the point I . In cases when the blood 



EXAMINATION OF THE BLOOD. 1 4 1 

is near the normal, a dilution of I : 200 should be used — that 
is, the pipet is filled to the point y 5 ^. Care should be taken to 
wipe off the point of the pipet before placing it into the dilut- 
ing fluid, which is sucked up to the point 101, and in doing 
so the pipet is gently tapped so as to mix the blood and pre- 
vent it from floating upon the top. The diluting solution 
must always be filtered before using. The pipet is now 
shaken so as to thoroughly mix the blood and the diluting 
fluid, and the fluid in the capillary portions is expelled. A 
small drop of the mixture is placed upon the counting stage 
and the cover-glass adjusted; when this has been done, we 
should be able to observe " Newton's rings " beneath the 
cover-glass and the top of the instrument. In adjusting the 
cover-glass care must be taken not to get any of the fluid or 
particles of dust beneath the cover-glass that is in relation to 
the top of the counting-chamber. The counting-stage is then 
carefully placed upon the stage of the microscope, caution being 
exercised to have it perfectly level. A fourth or fifth objective 
is best suited for counting. The number of corpuscles over- 
lying a given number of squares is now enumerated. If the 
distribution of corpuscles be uniform, 16 squares will be suf- 
ficient, otherwise a greater number should be used. The 
greater the number of squares employed in counting, the more 
accurate the result. Corpuscles found in relation to the upper 
and right-hand boundary line of a square are enumerated with 
it. In counting it is best to begin at the upper left-hand corner, 
16 squares, counting from left to right until 4 squares have 
been used, and then from right to left in the lower layer, and 
so on in this serpentine manner. 

The method of calculating the number of corpuscles per 
cubic millimeter is as follows : The number of corpuscles 
counted is multiplied by 4000 and this by the degree of dilu- 
tion, and the product divided by the number of squares em- 
ployed, the result being the number per cubic millimeter. 

Formula : 

Number of corpuscles counted X 4 Q o° X degree of dilution _ Number of corpuscles per 
Number of squares used in counting cubic millimeter. 

Carefully cleanse the pipet after using. After blowing out 
the solution it should be washed with a weak solution of acetic 
acid if Toisson's solution has been used ; if other diluting 
solutions are employed, it is rinsed with water ; next, it should 
be washed with alcohol and, finally, with ether ; a column of 



142 LABORATORY METHODS. 

air being then passed through so as to thoroughly dry the 
instrument. It will be found laborious to fill and empty the 
tube. A pump or atomizer bulb may be used for the purpose 
of blowing out the fluid. A much easier method is to have 
a rather firm piece of rubber tube attached to the pipet, which, 
when twisted and the end firmly compressed between the 
fingers, will be found to drive the fluid from the tube. If the 
tube be placed in a fluid and the rubber tube straightened by 
untwisting, a vacuum is created, thus causing the fluid to flow 
into the tube. After having rinsed the tube with ether or 
alcohol it is best dried by holding it some distance from a 
flame, — not allowing the flame to touch the glass, — and then 
by a series of twists as just described the air rushes in and out, 
and the apparatus is thoroughly dried in a few minutes. 

Enumeration of White Corpuscles. — In order to more 
accurately enumerate these corpuscles, a pipet having a capil- 
lary portion of larger bore than that for counting the red 
blood-corpuscles is used, so that a dilution of 1 : 10 is secured. 
The fluid used for this purpose is a watery solution of acetic 
acid, the strength of which is from y 2 % to 1 % . This serves 
to dissolve the erythrocytes, rendering the white corpuscles 
more plainly visible. The method of counting is similar to 
that described for enumerating the erythrocytes, except that 
for the white corpuscles a stronger dilution, 1 : 10 or 1 : 20, is 
employed. Other methods have been used for counting the 
corpuscles, such as by the hematokrit, the Oliver tintometer, 
Gowers' hemocytometer, and by Durham's modified hemo- 
cytometer, descriptions of which will be found in special works 
upon the blood. 

Blood Staining. — In order to study the more minute struc- 
ture of the blood it is necessary to stain it ; before doing this, 
however, a cover-slip preparation must be fixed. Cover-glass 
specimens are prepared by taking a thin cover-glass (which 
should be scrupulously clean), and allowing it to touch a 
drop of blood without coming in contact with the skin. This 
is permitted to fall upon a clean cover-glass, the two cover- 
glasses being rapidly drawn apart without lifting. The speci- 
mens are fixed preferably by heating to a temperature of from 
130 to 150 C, for from fifteen to- thirty minutes, in an oven 
or upon a copper plate. This method of fixation is always 
employed when using Ehrlich's stain. The covers may also 
be fixed by immersion in equal parts of absolute alcohol and 
ether, being immersed for half an hour. Other methods of 



EXAMINATION OF THE BLOOD. 1 43 

fixation are sometimes employed, such as solutions of formal - 
dehyd or absolute alcohol. 

Staining. — The method most often employed is the one 
proposed by Ehrlich. This stain consists of — 

Saturated aqueous solution of orange G 6 parts 

Saturated aqueous solution of acid fuchsin . ... 4 " 

These solutions are mixed, and then is added — 

Saturated aqueous solution of methyl-green . . .6.6 parts. 
To this mixture is added — 

Glycerin (neutral) , . 5 parts. 

Absolute alcohol 10 " 

Water 15 " 

The mixture should be shaken and allowed to stand for 
twenty-four hours. It must not be filtered. The cover-glass 
spreads are stained for five minutes with Ehrlich' s tricolored 
mixture, then washed with water, dried well, and mounted in 
Canada balsam. To intensify the nuclear stain after employ- 
ing Ehrlich's mixture, it is advisable to stain the specimen for 
ten or twenty seconds with a saturated aqueous solution of 
methyl-green. For differential counting it is essential to use 
this stain ; but for the demonstration of nuclei or malarial 
parasites, a double stain, using a more intense nuclear dye, is 
preferable. The specimen should then be fixed in alcohol and 
ether. The stain ordinarily employed consists of the follow- 
ing procedure : Stain the specimen with a solution consist- 
ing of y 2 % of eosin, 50 parts of alcohol, and 50 parts of 
water, for from three to five minutes. Wash the stain off with 
water, and, finally, stain with some nuclear dye, such as a 
solution of hematoxylin, methylene-blue, or toluidin-blue, for 
from two to five minutes. Wash with water, dry, and mount 
with Canada balsam. 

Description of the Erythrocytes. — The number of red 
cells per cubic millimeter in health is 5,000,000 in an adult 
male, and 4,500,000 in an adult female. This number varies 
somewhat under normal conditions : In strong;, full-blooded 
individuals 6,000,000 corpuscles are sometimes seen. An 
increase in the number of red cells is termed polycythemia, 
which may be met with, as just mentioned, in vigorous indi- 
viduals, in early childhood, in high altitudes, in cyanosis, and 
from blood concentration, the latter being produced after 
severe diarrhea, vomiting, or excessive sweating ; hence, this 



144 LABORATORY METHODS. 

is met with in cholera, and at the crisis in some of the acute 
infectious diseases. 

A decrease in the number of erythrocytes is termed oligo- 
cythemia. This condition is encountered as a result of men- 
struation, pregnancy, childbirth, lactation, after meals, fatigue, 
and direct blood loss, and in the primary and secondary 
anemias ; the greatest reduction is found in pernicious anemia. 

The red blood-cell (erythrocyte) is a biconcave disc measur- 
ing about 7. 5 microns in diameter. The size, however, varies 
somewhat under normal conditions: 75^ of the corpuscles 
measuring exactly 7.5 microns in diameter, while 25^ vary 
from 6 to 9 microns in diameter. The erythrocyte is of a 
yellowish-green color, and consists of a delicate stroma — 
called the stroma of Rollett — in the meshes of which is held 
the hemoglobin as an albuminate, which is soluble in water. 
It stains with the acid dyes ; with Ehrlich's triple stain it 
has a selective affinity for the aurantia. The tendency to 
rouleaux formation and crenation occurs normally. Its ab- 
sence is abnormal. The size of the red corpuscles varies 
under pathologic conditions ; a small corpuscle is called a 
microcytc. When a number of corpuscles are below the 
average size, the condition is termed microcytosis. This is 
commonly met with in chlorosis and in some of the secondary 
anemias. In this condition the percentage of hemoglobin is 
lower than the percentage of the corpuscles. A large red 
corpuscle is called a macrocyte ; and when a number of cor- 
puscles are found larger than normal the condition is called 
macrocytosis. This condition is frequently met with in pro- 
gressive pernicious anemia, in which affection the percent- 
age of hemoglobin is greater than the percentage of red cor- 
puscles. An erythrocyte having a distorted outline is called 
a poikilocyte. When a number of the erythrocytes present 
this appearance, the condition is known as poikilocytosis. The 
shapes assumed by the corpuscles vary greatly — they may. be 
pear-shaped, dumb-bell-shaped, etc. This condition may be 
due to artifacts. When this is the cause, the long diameters 
of the distorted corpuscles are almost in parallel lines, and is 
caused by the sliding apart of the cover-glass in making 
the spreads. Pathologic poikilocytosis occurs in all severe 
anemias, especially in progressive pernicious anemia. 

Nucleated red corpuscles are found normally in the blood 
of the embryo up to the seventh month ; occasionally, they 
may be found at birth. The varieties of nucleated cells are 



EXAMINATION OF THE BLOOD. 145 

the normoblasts, the megaloblasts, the microblasts, and the poi- 
kiloblasts. 

The normoblast is about the size of the normal erythrocyte, 
and has a nucleus that occupies one-third or one-half of the 
cell. When stained with Ehrlich's triple mixture, the peri- 
nuclear protoplasm stains a faint or light-yellow color, while 
the nucleus is colored a dark-green or blue. Occasionally, it 
is found that there appears about the nucleus a faint hyaline or 
clear space denoting a separation between the nucleus and the 
perinuclear protoplasm. The nucleus may occupy the center 
or the periphery 7 of the cell, in some instances extruding from 
the cell. It may present variations as to the staining reaction, 
being darker in some places and lighter in others ; and, 
rarely, there are mitotic figures. This cell is normally found 
in the bone-marrow, and probably represents an early stage in 
the development of the erythrocyte. After copious hemor- 
rhage these cells are found in the circulating blood, and it ap- 
pears that they are thrown into the circulation before the 
matured cell is developed. They are also found in great num- 
bers in splenomedullary leukemia, the bone-marrow in this 
disease revealing marked proliferative changes. 

The mcgaloblast is a very large nucleated red cell, its size 
varying from ten to twenty microns in diameter. It has a 
large nucleus, which possesses a weak selective affinity for the 
basic stains. When treated with Ehrlich's tricolored mixture, 
it is colored a robin's-egg blue, the stain being either uniformly 
distributed or, in some instances, irregularly. Around this 
nucleus there appears an unstained area, it being separated 
from the perinuclear protoplasm, the latter often revealing de- 
generative changes, so that it does not take up the acid stain 
properly, and is of a brownish-red color. -The megaloblast 
probably represents a fetal type of cell development. It is 
never found in normal bone-marrow in the adult, but in fetal 
marrow, and in the blood and marrow of some of the grave 
forms of anemias. 

The microblast is a small cell containing a deep-staining 
nucleus ; it is less frequently found than the cells just de- 
scribed. 

When the red blood-cell is distorted and contains a nucleus 
it is called a poikiloblast. This cell must be regarded as hav- 
ing the same clinical significance as the megaloblast, and, like 
that cell, often shows degenerative changes in the perinuclear 
protoplasm. 
10 



I46 LABORATORY METHODS. 

Double and triple nucleated red blood-cells are sometimes 
encountered, notably in splenomedullary leukemia. 

The normal erythrocyte possesses the power of selecting 
acid dyes, such as eosin, acid fuchsin, picric acid, and auran- 
tium. Under certain conditions the staining reaction is altered, 
so that the cell will take up not only acid dyes, but a mixture 
of acid and basic dyes, and under such circumstances, when 
stained with Ehrlich's triple mixture, the cell is of a brownish- 
yellow or brownish-red color. When these changes are en- 
countered, they should be regarded as evidences of degenera- 
tion (polychromatophilic red corpuscles). 

In the stained preparations faint rings are sometimes 
noticed, the protoplasm of the same having been washed out. 
These cells are known as shadozv or phantom corpuscles. 

The Hemoglobin. — In the normal state the hemoglobin is 
contained in the red blood-cell as a soluble albuminate ; a! de- 
ficiency in the hemoglobin indicates a loss of albumin. Every 
100 grams of blood represent 14 grams of hemoglobin, 
which is expressed as being 100%. In all forms of anemia 
the hemoglobin is decreased. When the percentage of hemo- 
globin and the percentage of erythrocytes are equal, it may be 
inferred that each red blood-cell possesses a correct amount 
of coloring-matter, this being termed the color index, or cor- 
puscular richness, in hemoglobin. When the erythrocyte 
possesses the normal amount of coloring-matter, it is said that 
the color index is normal, or equals 1 ; when the cell contains 
less hemoglobin than normal, it is said that the color index is 
low ; when it contains an excess, we speak of the color index 
as high, or above 1. The exact index is determined by 
dividing the percentage of hemoglobin by the percentage of 
red corpuscles ; for example, if the number of red cells is 
5,000,000 per cubic millimeter, or 100%, and the hemo- 
globin be 50^, the color index will be 0.5. The hemoglobin 
is more difficultly regenerated than the red blood-corpuscles, 
so that in nearly all forms of anemia the color index is low, 
except in progressive pernicious anemia, when it is usually 
high. 

The Leukocytes. — In the healthy adult there are from 
6000 to 8000 white blood-cells per cubic millimeter in the 
peripheral circulation. Increase in the number of leukocytes 
is termed leukocytosis. This may be either physiologic or 
pathologic. A physiologic leukocytosis is encountered dur- 
ing pregnancy, during digestion, in the new-born, and just 



EXAMINATION OF THE BLOOD. 1 4/ 

before death, the latter being called agonal or terminal leuko- 
cytosis. It is also encountered after exercise, bathing, and 
massage. Pathologic leukocytosis may be due to inflamma- 
tory or infectious causes, when it is termed inflammatory leuko- 
cytosis ; or after hemorrhage, when it is called posthemorrhagic 
leukocytosis. Leukocytosis is met with during the course of 
sarcoma and carcinoma, known as malignant leukocytosis ; 
when resulting from toxic changes, it is called toxic leuko- 
cytosis. 

Inflammatory leukocytosis is met with in nearly all inflam- 
mations and infectious diseases, except enteric fever, tubercu- 
losis, malaria, influenza, measles, and rotheln. When the 
resisting powers of the individual are good, a slight leukocy- 
tosis is encountered from mild infections ; and a marked 
leukocytosis, from severe infections. When the resisting 
powers of the individual are feeble, no leukocytosis is encoun- 
tered from very severe infections. It is said that with over- 
whelming infections even with good resisting powers there is 
no increase in the number of white blood-cells. After copious 
hemorrhages a leukocytosis of from 10,000 to 20,000 is met 
with. Malignant leukocytosis is encountered during the 
growth of sarcoma and carcinoma ; the former, as a rule, 
revealing a more marked leukocytosis than the latter, so that 
a leukocytosis of from 20,000 to 50,000 rather indicates sar- 
coma than carcinoma. 

Leukopenia (Hypoleukocytosis). — These terms are used 
to express a decrease in the number of white blood-cells in 
the peripheral circulation. It is met with in the following 
conditions : starvation and prolonged cold bathing ; and 
sometimes in tuberculosis, malaria, enteric fever, and per- 
nicious anemia. 

Varieties of Leukocytes. — /. Polymorphonuclear Neutro- 
phil . — This cell is sometimes termed the polynuclear leukocyte 
or the finely granular oxyphilic cell. It measures about 13^ 
microns in diameter, is ameboid, and phagocytic. It pos- 
sesses a nucleus that is irregular in shape, lobulated or twisted, 
and often appears as though there were many of them ; hence 
the name polynuclear leukocyte. When the cell is stained with 
strong basic dyes, it will be found that there is always a sin- 
gle nucleus, the lobulated portions being joined by chromatin 
bands. When stained with Ehrlich's triple mixture, reddish- 
brown or purple granules are seen in the portion of the cell 
surrounding the nucleus. These granules possess a marked 



I48 LABORATORY METHODS. 

affinity for the acid stains, so that the term " finely granular 
oxyphilic cell" seems to be more properly applied. This is 
the most frequent leukocyte encountered in normal blood ; 
it forms from 60 fo to 70 fo of all the leukocytes. 

2. The Eosinophil, Poly nuclear Eosinophil, or Coarsely Gran- 
ular Oxyphilic Cell, — This white blood-corpuscle measures 
about twelve microns in diameter ; it is ameboid, but is said not 
to be phagocytic ; it possesses a nucleus similar to that seen in 
the polynuclear neutrophile. In the perinuclear protoplasm are 
seen granules that are large and spheric in outline ; these have 
a strong affinity for acid dyes, and when stained with eosin 
appear as bright-red bodies; hence the term " eosinophile." 
They form from Y^fo to 4^ of the leukocytes in normal 
blood. When they occur in large numbers, the term eosinophilia 
is employed. This condition is met with in asthma, in some 
of the diseases of the skin, and in trichinosis. Under normal 
conditions they are found in large numbers in the serous cav- 
ities. 

j . The Small Lymphocyte or Small Mononuclear Cell {some- 
times called the Small Hyaline Cell). — This cell is the smallest 
of the leukocytes, its average diameter being about ten 
microns. It possesses a single large nucleus that occupies 
the greater portion of the cell, and is surrounded by a thin 
rim of protoplasm. The nucleus reacts to the basic dyes with 
marked affinity, so that when it is stained with Ehrlich's mix- 
ture it appears blue. The protoplasm reacts faintly to the acid 
dyes, and with the triple mixture stains a light pink. Sometimes 
it stains a pale-blue color. This is met with when the basic 
stain is in excess. The small lymphocytes comprise from 
20 f c to 30 f of all the leukocytes in normal blood ; they 
are, however, found in large numbers in the lymphatic chan- 
nels. In some diseases the lymphocytes are increased ; this is 
met with in lymphatic leukemia and progressive pernicious 
anemia. The cell does not possess ameboid or phagocytic 
properties. 

/j.. The Large Lymphocyte, Large Mononuclear or Hyaline 
Cell. — The size of this leukocyte is about thirteen microns in 
diameter. It is ameboid and phagocytic. Its morphology 
closely resembles that of the small lymphocyte, except that 
the cell is larger ; the nucleus, however, is not so large in 
proportion to the size of the cell, and has a weaker affinity for 
the basic dyes. It comprises from 4% to Sf of the leuko- 
cytes. 



EXAMINATION OF THE BLOOD. 1 49 

5. The Mast-cell or Coarsely Granular Basophilic Leukocyte. 
— This cell is said to occur in normal blood in the proportion 
of from -^fo to j4fo- It is found more frequently in the 
blood of certain forms of leukemia. It possesses a nucleus 
that is twisted or lobed, and in the perinuclear protoplasm 
there are found very coarse granules that react to basic stains. 
Mast-cells are found abundantly in some connective tissues ; 
they are described as having granules, possessing a modified 
basophilic reaction — that is, when they are stained with tolu- 
idin-blue and treated with glycerin-ether or a weak oxalic acid 
solution, the color of the stain is modified from blue to pur- 
ple or red. The five varieties of leukocytes just described are 
found in normal blood. 

Under certain pathologic changes another cell, called the 
myelocyte, may be found. 

The Myelocyte {Marrow Cell or Mark Cell). — This cell is 
normally found in the bone-marrow. As a rule, it is quite 
large, the average diameter being about 15.75 microns; the 
variation in size is from 10 to 20 microns. It may be de- 
scribed as having a large, pale-staining nucleus, the contour of 
which varies from the round oyal to the lobe shaped. There 
is a faint rim of protoplasm around this nucleus, which con- 
tains granules. They may be fine and react to the acid stains 
(hence the name neutrophilic myelocyte or finely granular 
oxyphilic myelocyte) ; the granules may be coarse and react 
to the acid stains (eosinophilic myelocytes or coarsely granular 
oxyphilic myelocytes) ; or, in some rare instances, they may 
contain fine granules which react to the basic stain. 

The myelocyte is easily differentiated from the large lymph- 
ocyte in that the latter does not contain granules. It is also 
easily differentiated from the polynuclear neutrophile in that 
the former possesses a large, pale-staining nucleus. The 
nucleus of the myelocyte sometimes reveals an irregular stain- 
ing reaction, and, occasionally, vacuoles are noted. This cell, 
as above stated, only appears in the circulating blood under 
morbid conditions, it being found in large numbers in spleno- 
medullary leukemia. 

Blood Plates. — These bodies are found in the blood as 
irregularly shaped masses about one-half the size of the 
erythrocyte, and are usually found in clumps or large masses. 
They are rather difficult to demonstrate in a fresh specimen 
of blood, and appear as colorless plates. A cubic millimeter 
of normal blood contains from 20,000 to 700,000 of these 



150 LABORATORY METHODS. 

bodies. From a clinical standpoint they are of little import- 
ance. A decrease in the number is met with in purpura and 
hemophilia. They are increased in leukemia. 

Miiller's Blood Dust (Hemokonien). — In normal and abnor- 
mal blood small hyaline refractive bodies, possessing a dancing 
molecular motion, are frequently seen. Their shape is not 
constant, frequently appearing as dumb-bell masses. They 
are of no clinical significance. 

Chemic Examination of the Blood. — The clinical value 
of the chemic examination of the blood at the present time 
is of little practical significance, since it is not well understood, 
the technic being also lacking. 

A very small amount of grape-sugar is present in normal 
blood, which is increased in diabetes mellitus. In gout 
minute quantities of uric acid are found in the blood, and in 
jaundice bile will be found. The methods for clinical deter- 
mination of these substances have not been perfected suffi- 
ciently to be of any practical clinical value. 

When fat is found in the blood, the condition is termed 
lipemia. This is met with in diabetes mellitus, in chronic 
alcoholism, and in chronic nephritis. 

When acetone is found in the blood the condition is termed 
acetonemia. It occurs in fevers, and particularly in diabetes. 

When excrementitious substances that are particularly de- 
rived from urinary products collect in the blood, a clinical 
condition arises called uremia. 

The most common inorganic constituent of the blood is 
sodium chlorid, which is found in the proportion of j4 of 1 fo. 

Micro-organisms Found in the Blood. — The most common 
of these is the spirillum of relapsing fever, which is described 
in the chapter on Bacteriology. The bacillus of anthrax, tuber- 
culosis, glanders, bacillus typhosus, influenza, and coli com- 
munis are rarely found in the blood. The staphylococcus and 
the streptococcus have also been described as occurring in the 
blood. (For description of these micro-organisms, see chapter 
on Bacteriology.) 

Animal Parasites Found in the Blood. — The plasmodium 
malarise is the most common animal parasite met with in the 
blood. (For description, see page 198.) The distoma haema- 
tobium and filaria sanguinis hominis are blood parasites. 
(For description, see section on Parasites.) 



Description for Plate I. 

Figures I to 35, inclusive, stained with Ehrlich's triple mixture; Figures 36 
to 51, inclusive, stained with eosin and toluidin-blue, as recommended by Harris. 

Figs. 1, 2, 3. — Polymorphonuclear neutrophiles. 

Figs. 4, 5, 6. — Eosinophiles. 

Fig. 8. — Small lymphocyte. 

Fig. 12. — Large lymphocyte. 

Figs. 7, 9. — Small lymphocytes (from the blood in lymphatic leukemia, showing 
atypical staining reaction). 

Figs. 10, 11. — Large lymphocytes (also showing atypical staining). 

Figs. 13, 14. — Myelocytes (with neutrophilic granules). 

Fig. 15. — Myelocyte (with eosinophilic granules). 

Figs. 16, 17. — Erythrocytes. 

Figs. 18, 19. — Erythrocytes showing normal variation in size. 

Figs. 20, 21. — Macrocytes. 

Figs. 22, 23. — Microcytes, 

Figs. 24, 25, 26, 27, 28. — Poikilocytes. 

Figs. 29, 30. — Normoblasts. 

Figs. 31, 32. — Red blood-cells, showing irregularly shaped nuclei. 

Fig. ^T>- — Megaloblast. 

Fig. 34. — Microblast. 

Fig. 35. — Erythrocyte, showing degenerative changes as demonstrated by the 
polychromatophilic reaction. 

Figs. 36, 37, 38. — Polymorphonuclear leukocytes. 

Figs. 39, 40. — Eosinophils, 

Figs. 41, 42, 43. — Small lymphocytes. 

Figs. 44, 45. — Large lymphocytes. 

Figs. 46, 47. — Myelocytes. 

Figs. 48, 49, 50. — Erythrocytes. 

Fig. 51. — Normoblast. 



Plate I. 



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EXAMINATION OF THE URINE. I 5 I 



EXAMINATION OF THE URINE. 

The normal quantity of urine in twenty -four hours is I 500 
c.c. ; however, this amount varies greatly, depending upon 
many physiologic and pathologic changes. The amount of 
urine shows diurnal variation — the greatest activity in the flow 
being during the day ; this is less at night and in the early 
morning. The amount is increased after partaking of fluid, 
anxiety, or excitement. 

The urine is light amber or a pale straw color, varying to a 
reddish-yellow. When it becomes concentrated, the shade 
becomes darker ; and when diluted, it is lighter. The pig- 
ments found in the urine that are of the most importance are 
urobilin and indican. The urine is perfectly clear and trans- 
parent, but upon standing a slight sediment or cloudiness is 
noticed, this being due to mucus. It occurs in nearly all 
forms of normal urine. Sometimes under normal conditions, 
after it becomes cool, uric acid salts deposit. 

The specific gravity varies between 10 15 and 1020, depend- 
ing on the degree of concentration and the amount of solids, 
which vary somewhat with physiologic conditions. The 
specific gravity is. determined by the use of the ordinary urin- 
ometer. The amount of solids that are found in twenty -four 
hours in normal urine ranges from 60 to 70 grams. 

During the course of twenty-four hours the reaction of the 
urine varies somewhat, but it is always acid. With a mixed 
diet the acidity decreases, but some hours after a meal the 
reaction again becomes decidedly acid. The urine may give an 
amphoteric reaction ; by this is meant that red litmus is ren- 
dered blue, and blue litmus red. 

It has a faint aromatic odor, but this varies, depending 
largely upon the diet. After eating asparagus it emits a 
stench ; after onions or garlic there is a garlicky odor ; and 
after partaking of certain drugs, such as turpentine, there is an 
odor resembling that of violets. Copaiba, cubebs, asafetida, 
musk, valerian, and castor oil produce a faint odor similar to 
that produced by turpentine. 

Micro-organisms are found in normal urine, such as the 
bacteria urea and the micrococcus urea, often the smegma 
bacillus. 

The amount of urea passed in twenty-four hours by a 
healthy adult is from 25 to 40 grams. The amount of 
uric acid passed in twenty-four hours is 0.66 gram. This 



152 LABORATORY METHODS. 

varies within wide limits. The amount of sodium chlorid 
passed in twenty-four hours is from 10 to 16 grams. Very 
faint traces of bile pigments are noted in normal urine. 

Alterations in the Amount Secreted. — An increase in the 
amount of urine is called polyuria. It may result from an in- 
creased arterial pressure, arising from the partaking of water 
and some drugs, as digitalis, caffein, etc. ; it may result 
from nervous causes, as in hysteric individuals ; also in dia- 
betes mellitus and insipidus ; in chronic interstitial nephri- 
tis ; diseases of the brain, such as irritation of the floor of the 
fourth ventricle ; from hemorrhage into certain parts of the 
brain ; and from the partaking of large quantities of liquids, 
as beer, wine, and coffee ; also from the resorption of edema 
and transudates. During the convalescence of some of the 
fevers, and particularly during the crisis (critical discharges), 
there is an increase in the amount of the urine, and finally a 
sudden increase is noted temporarily, resulting from the relief 
of an obstruction to some part of the conducting apparatus, 
as from the plugging up of the ureter by stone or from spas- 
modic contraction of the urethra, etc. 

A decrease in the quantity of urine is called oliguria. This 
is caused by a decrease in the blood pressure, which occurs 
from failing heart compensation ; from slowing of the circula- 
tion through the kidney, as from embolus in the renal artery ; 
also from increased sweating or diarrhea, as is common in 
choleric diseases ; and from obstinate vomiting. During the 
course of the fevers the amount is decreased. It may be due 
to nervous causes, such as shock ; also in disease of the 
kidney, such as acute and chronic parenchymatous nephritis. 
Diseases of the conducting apparatus may cause a damming 
back of the flow of the urine, as is common in stricture of 
the urethra. In uremia the flow of urine is always diminished 
and sometimes completely absent. After severe hemorrhages, 
particularly internal hemorrhages, the amount of urine is de- 
creased. This depends upon the lowering of the arterial 
pressure. After the removal of a kidney the amount may be 
temporarily decreased, the other kidney from reflex action 
failing to secrete urine. 

Color. — Various diseases produce changes in the color of 
the urine. Blood in the urine (hematuria) is caused by the 
presence of red blood-corpuscles in the urine, the color being 
of a reddish hue. If free hemoglobin be found, it is called 
hemoglobinuria. In this condition the urine is of a reddish 



EXAMINATION OF THE URINE. 1 53 

color, varying to a brownish-black, the intensity of the color 
depending upon the amount of blood pigment present. When 
blood is derived from the bladder, the first that is passed will 
contain a smaller amount of blood than the last. Blood from 
the bladder may be copious in amount, and this urine, in con- 
trast to that containing blood from the kidney, upon standing 
will show fibrin. Blood from the kidney is more likely to be 
intimately mixed with the urine, and if coagula be present, 
they are apt to be washed out. From the urethra, only the 
last drops are likely to be bloody. Hemoglobinuria occurs 
from a number of causes, the most important being malaria, 
variola, purpura, scurvy, thermic fever, and large burns of the 
skin ; also from certain drugs, as chlorid of potassium, pyro- 
gallic acid, quinin, or carbolic acid. When bile is mixed with 
the urine, as occurs in various forms of jaundice, the color 
becomes dark yellow, yellowish-green, brownish, or even 
porter color. The foam upon the urine is retained for some 
time. 

In chyluria or galacturia the urine has a milky or chylous 
appearance. If it is allowed to stand, a fatty deposit will ap- 
pear upon the surface, and upon microscopic examination of 
this material fat is observed, which is dissolved by ether or 
alcohol. Chyluria is principally met with in the tropics, and 
is due particularly to the filiaria sanguinis hominis. The urine 
may slightly change in color as the result of fat, which occurs 
from the following causes : In diseases of the kidney, such as 
chronic parenchymatous nephritis, pyonephrosis, or sperma- 
torrhea ; in the severe cachexias, -such as tuberculosis, yellow 
fever, pyemia, or poisoning from coal-gas and phosphorus. 
Melamiria is due to melanin being present in the urine. This 
gives rise to a brownish or blackish discoloration after the 
urine has been standing, even if it was passed clear. This 
condition takes place in melanotic tumors, particularly sar- 
coma. Indicanuria gives rise to a bluish or bluish-black 
appearance of the urine, and results from the following con- 
ditions : The accumulation of feces from obstinate constipa- 
tion, from peritonitis, from severe cachexias, and from intes- 
tinal catarrh. The color of the urine is often influenced by 
drugs : from methylene-blue, the urine becomes blue ; from 
carbolic acid, creosote, salol, and the coal-tar products, it be- 
comes greenish-black ; from hematoxylin or log-wood the 
color becomes reddish or purplish ; from santonin and picric 
acid, it becomes yellowish-green in color ; and from juniper 



154 LABORATORY METHODS. 

berries, rhubarb, senna, and chrysarobin, it becomes purplish- 
red. Cloudiness or turbidity may 'result from an increase of 
mucus, from phosphates, urates, blood, pus, chyle, epithelial 
cells, and numerous bacteria. 

The specific gravity of the urine in disease varies within 
wide limits, from somewhat over 1000 to 1074. High specific 
gravity is found in the following diseases : in fevers, from 
failure of heart compensation, acute and chronic parenchyma- 
tous nephritis. A very high specific gravity of the urine 
occurs in sulphuric acid poisoning. It also often takes place 
after the use of certain remedies, such as diuretics, liquors, 
potassium acetate, and different tartrates. Very high specific 
gravity is met with in diabetes mellitus ; low specific gravity is 
encountered in the following diseases : chronic interstitial 
nephritis and diabetes insipidus. The specific gravity may be 
as low as 1002. 

Reaction of the Urine in Disease. — Neutral or alkaline 
reaction of the urine may result from the ingestion of alkalies 
(except ammonia), from the resorption of large transudates and 
exudates, or hemorrhages, or from free blood in the urine, and 
sometimes after hot and cold baths. The urine may be alkaline 
as the result of gastrectasis. This is especially so if accom- 
panied by frequent vomiting. It may also result from fermen- 
tation of the urine in the bladder, particularly when mixed with 
large amounts of pus. 

Acidity of the Urine. — Hyperacidity is of very little diag- 
nostic importance. For practical clinical purposes the reaction 
of the urine is determined by litmus paper. 

Chemic Examination of the Urine. — The occurrence of 
albumin in the urine is called albuminuria. In the majority of 
cases it is either serum albumin or seroglobulin (paraglobulin). 
Albumin results from diseases of the kidney, in fevers, and 
acute poisoning. It may also result from the admixture of 
blood or pus. 

True or renal albuminuria is due to diseases of the 
kidneys themselves, while toxic albumin appears as the result 
of toxemia. 

Test for Albumin. — When the urine is cloudy, it should 
be filtered, and the filtrate tested. Mucin-like substances may 
resemble the reaction for albumin. This is best avoided by 
acidulating the urine with acetic acid and filtering. Repeated 
filtrations are sometimes necessary. 

Heat and Acid Test. — The urine is placed in a test-tube, and 



EXAMINATION OF THE URINE. 



155 




boiled ; if albumin be present, a white precipitate will be noted. 
If cloudiness result after boiling, it may.be due to phosphates, 
but on the addition of acid (nitric or acetic) the phosphates will 
clear up, and albumin will be precipitated. 

Heller 's Test. — This is performed by placing a quantity of 
nitric acid at the bottom of a test-tube and allowing the urine 
to flow gently down the side of the tube, so that the urine 
overlies the nitric acid ; if albumin be present, a white disc 
is formed at the point of contact. If urates 
be present, a yellowish-white disc may appear 
at the junction of the two liquids. This is 
often misleading. Upon the gentle applica- 
tion of heat the urates disappear and the al- 
bumin remains. 

The Test by Acetic Acid and Potassium Fer- 
rocyanid. — The method suggested by v. 
Jacksch is as follows : Acetic acid and a few 
drops of a solution of ferrocyanid of potassium 
are placed in a test-tube, and the urine is 
superimposed upon this mixture. If albumin 
be present, a white disc will appear at the 
line of contact. This is a very delicate test. 

The Picric Acid Test. — This test is best 
accomplished by placing urine in a test-tube 
and allowing a saturated solution of picric 
acid to flow gently into the tube ; if albumin 
be present, a white disc will form at the line 
of contact, and at this point a diminished 
transparency is noted. If the patient has been 
taking quinin, thallin, antipyrin, or potassium 
salts, the picric acid test will be open to fal- 
lacies, as thick precipitates may appear that 
are not albumin. It is also obtained by the 
presence of mucin. 

Quantitative Test. — The Esbach albumin- 
ometer (Fig. 23) consists of a somewhat thick- 
ened test-tube, which is graduated and divided 
into eight lines beginning at y 2 and then 
going to 7. There are two divisions, one 
marked "U" and the uppermost marked " R." 
The urine is poured into the tube to the point 
marked " U " (urine), and the reagent to the mark " R 




Fig. 23. — Esbach's 
albuminometer. 



The 



reagent fluid consists of 10 grams of picric acid, 20 grams of 



I56 LABORATORY METHODS. 

citric acid, and 1000 grams of water. The tube is then corked 
with a rubber cork, shaken, and allowed to stand for twenty- 
four hours. If the precipitate should reach to the division 2, 
this would signify that 1000 c.c. of urine contain 2 grams of 
albumin, or a 0.2%. Each mark represents T V%- If the 
amount should reach to the figure 7, the urine must be diluted 
one-half, and the result multiplied by 2. The room in which 
the test is made should not have too low a temperature. In 
urines that contain less than 0.2^ of albumin, the condition 
is spoken of as slight albuminuria ; those in which the amount 
shows 0.8^ are known as medium albuminuria; and above 
his would be designated as great albuminuria. It is necessary 
in performing this test to take a sample of the total quantity 
collected during twenty-four hours. 

Test for Bile Pigments and Bile Acids. — MarechaVs Test. 
— If a few drops of an iodin solution (Lugol's solution) be 
added to urine containing bile pigment, a grass-green color 
rapidly develops, revealing the presence of bile pigment. 

Rosenbacli s Modification of Gmeliii s Test. — The urine is 
filtered ; the filter is unfolded, placed upon a porcelain plate, 
and upon it a few drops of a mixture of nitric and nitrous 
acids are poured. Color rings are produced — yellow, brown, 
violet, blue, and green — in which green predominates. This 
color reaction shows the presence of bile pigment. 

Grape=sugar. — The occurrence of grape-sugar in the urine 
is called glycosuria. In a number of pathologic conditions 
glucose is found in the urine, particularly in diabetes mellitus. 
In this condition the amount of sugar is frequently very large, 
varying from 2°fo to 10 °fo . The urine in this condition is greatly 
increased in quantity, is of high specific gravity, and is of a pale 
straw color, sometimes greenish. Glycosuria may be due to 
lesions of the floor of the fourth ventricle, such as tumors and 
cysts. It is met with in diseases of the liver, the pancreas, 
and occasionally results from the taking of large quantities of 
starches or sugars ; it is also sometimes met with during the 
course of certain nervous conditions, such as epilepsy, cerebral 
apoplexy, injuries to the nervous system, neuralgia, and exces- 
sive mental exertion ; also during pregnancy. It is sometimes 
encountered during the course of the acute infectious diseases, 
such as diphtheria, scarlet fever, cerebrospinal meningitis, 
typhus fever, enteric fever, and cholera ; from poisoning with 
amyl nitrite, mercury, morphin, carbonic oxid, chloral, prussic 
acid, sulphuric acid, and alcohol. Normal urine contains a 



EXAMINATION OF THE URINE. 157 

slight trace of sugar, which is termed physiologic glycosuria. 
Pathologic glycosuria results from any of the morbid conditions 
just enumerated. This form may be transitory, when grape- 
sugar appears in the urine for a short time ; or the sugar may 
be found in the urine constantly, when the condition receives 
the name of persistent glycosuria. The latter condition is 
met with in diabetes mellitus. 

Tests for Grape=sugar. — Trommer's Test. — A small quan- 
tity of urine is added to one -fourth of its bulk of liquor potassse, 
and to this mixture is added, drop by drop, a solution of 
cupric sulphate. The mixture is then boiled ; if grape-sugar 
be present, a precipitate will form, which is yellowish or red in 
color, the substance being suboxid of copper. This test is 
quite delicate, and o.ooi part of sugar may be detected ; how- 
ever, some substances, when found in the urine, may give the 
reaction, such as uric acid, milk-sugar, kreatinin, bile pigments, 
chloral, and after the ingestion of benzoic and salicylic acid. 
If the urine contains large amounts of grape-sugar, the reduc- 
tion takes place at a temperature below the boiling-point. 

Fehling' s Test. — This test may be substituted for Trommer's 
test. Fehling 's Solution : This fluid must be freshly prepared 
before using, or the solutions can be kept separate and mixed 
when desired. 

Solution (A) : 34.639 grams of copper sulphate are dissolved 
in 100 grams of water by gently warming, and this is diluted 
to 500 grams. 

Solution (B) : To 173 grams of sodium tartrate are added 
100 grams of a solution of sodium hydrate having a specific 
gravity of 1034, and this solution is dissolved in water until 
the mixture equals 500 grams. 

To perform the test, equal parts of solutions A and B are 
mixed in a test-tube and diluted with four parts of water. This 
mixture is boiled ; if the color remains blue, the solution has 
not spoiled. The urine is now poured into the test-tube, drop 
by drop, and gently boiled, and when sugar is present, the 
color changes to a yellowish or red color, the cupric sulphate 
being reduced. If upon boiling the color of the Fehling solu- 
tion is not changed, and no precipitate forms, sugar is absent. 

This solution may be used as a quantitative test, as it 
requires 0.05 gram of grape-sugar to reduce 10 c.c. of Fehl- 
ing's solution. When using the quantitative method, the 
urine should always be diluted, the degree of dilution depend- 
ing upon the amount of sugar present. 



I58 LABORATORY METHODS. 

Fermentation Test. — Yeast decomposes grape-sugar into 
alcohol and carbonic acid. This test should always be em- 
ployed when reducing-substances are suspected in the urine 
which are not grape-sugar. The method is applied as follows, 
the test being that recommended by Dr. Roberts : Four 
ounces of diabetic urine are placed in a twelve-ounce bottle 
and compressed yeast is added to this ; the bottle is then 
lightly corked, so as to permit the carbonic acid to escape. 
This is set in a warm place. Another bottle containing four 
ounces of urine, tightly corked, is placed alongside of this. 
Fermentation will be complete in about twenty-four hours. 
After this time the specific gravity is taken of the fermented 
and the unfermented urine. It will be noted in the diabetic 
urine that after fermentation the specific gravity will be low- 
ered. The number of degrees in specific gravity lost is deter- 
mined, and this result multiplied by 0.23 ; the result will 
equal the percentage of sugar. The fermentation test is quite 
delicate — o. I % of sugar is detected in the urine. Special 
fermentation tubes are sometimes employed. The polariscope 
is used to determine the presence of sugar. 

Acetone. — Very small traces of this substance are present 
in normal urine, the condition being termed physiologic aceton- 
uria. When it occurs in excessive amounts, it is termed 
pathologic acetonuria. This substance is increased in febrile 
conditions, in diabetes, psychoses, derangements of digestion, 
starvation, from auto-intoxications, carcinoma, and chloroform 
narcosis. When acetone appears in diabetic urine, it indicates 
an advanced state of the disease. 

Legal' s Test. — Four cubic centimeters of urine are rendered 
alkaline by the addition of liquor potassse, and to this is added 
a few drops of solution of sodium nitroprussid, a red color 
being produced, which on the addition of acetic acid turns 
purple if acetone be present. 

Lieberis Test. — A small quantity of urine is distilled, the 
distillate being used for the test, to which is added a few drops 
of iodopotassic iodid solution and caustic potash. If acetone 
be present, a precipitate of iodoform crystals is deposited, 
which may be detected by its color and smell. 

Diacetic Acid. — This substance is never found in normal 
urine, and when present the condition is termed diaceturia. It 
occurs in some auto-intoxications, in febrile conditions, and 
diabetes. When diacetic acid is found in the urine, it is of 



EXAMINATION OF THE URINE. 159 

unfavorable diagnostic omen, and often indicates oncoming 
coma. Diacetic acid is accompanied by acetone. 

Test. — The urine should be boiled, and a solution of chlorid 
of iron be added, drop by drop. If diacetic acid be present, 
a Burgundy red color is produced. It sometimes happens 
that phosphates are precipitated in performing the test. If 
this occurs, the phosphates should first be removed by filtra- 
tion. 

Ehrlich's Diazo Reaction. — The test is performed as follows : 
The reagents must be freshly prepared, and are — (i) Hydro- 
chloric acid, 50 parts ; distilled water, rooo parts ; and sul- 
phanilic acid, 5 parts. (2) A 5 c / solution of sodium nitrite. 

Three grams of solution (1), with the addition of one drop of 
solution (2), are placed in a test-tube, and then an equal part 
of urine is added to this ; mix carefully, and add about one- 
eighth of the volume of ammonia. If a red color develops 
upon shaking the mixture, the diazo reaction is present. This 
reaction is obtained from the urine in certain morbid states, 
particularly enteric fever, measles, and acute tuberculosis. 
Von Jaksch believes that the color when obtained is always 
due to the presence of acetone, and he prefers to regard the 
process rather as an uncertain indication of that body than as 
a test for anything else. 

Urinary Sediments. — The urine is placed in a conic glass 
vessel, and allowed to stand for a number of hours so that the 
sediment will form in the pointed bottom, and then, by means 
of a pipet, it is withdrawn, placed upon a slide, and then a 
cover-glass is placed upon this. It is now ready for micro- 
scopic examination. The urinary sediment may be obtained 
by means of the centrifuge. When this instrument is available, 
the method is preferable, for when the urine is allowed to stand 
for any length of time changes develop, such as numerous 
micro-organisms. 

Organized Sediments. — These consist mostly of various 
cellular bodies. Epithelium. — The normal urine always con- 
tains some epithelial cells. These are derived from the bladder, 
from the ureters, the renal pelvis, and sometimes from the 
substances of the kidneys. In inflammation of the mucous 
membrane of the genito-urinary tract large numbers of epithe- 
lial cells are present in the urine. In women, especially those 
suffering from leukorrhea, a number of large, flat epithelial 
cells are found in the urine. It is difficult to differentiate 
between the cells derived from the bladder, ureter, and renal 



l6o LABORATORY METHODS. 

pelvis. Those cells which are derived from the superficial 
portion of the mucous membrane are polygonal and elliptic, 
and contain a single large nucleus. The cells which are 
derived from the deeper layers are more irregularly oval in 
outline and also contain a single large nucleus. When the 
cells are in great abundance, they often indicate inflammation 
of the bladder. The clinical symptoms of the disease in 
question are necessary to discern between disease of the pelvis, 
the ureter, or the bladder. Cells which are derived from the 
tubules of the kidney are usually polyhedral in shape, and con- 
tain a large oval nucleus ; but the shape of the cells varies, 
depending upon the portion of the urinary tubule from which 
they are derived. They may be found singly or coalesced, the 
latter indicating epithelial casts. The cells from the kidney 
often reveal degenerative changes — granular and fatty. The 
diagnosis of lesions of particular parts of the genito-urinary 
tract should never be based upon the shape of the epithelial 
cells alone, but other clinical manifestations of the disease in 
question must be taken into consideration-. 

Red BloocUcells. — Red blood-cells may occur in the urine 
without causing a change in color, and they may be dis- 
covered only by the aid of the microscope. They may be 
derived from any part of the genito-urinary tract. When these 
cells are intimately mixed with the urine, and upon micro- 
scopic examination appear as pale-yellow rings (phantom 
or shadow corpuscles), it may be inferred that their origin 
has been in the kidney, the pelvis, or the ureter, but a 
definite diagnosis should only be made if the other clinical 
facts coincide with the urinary findings. If the red blood-cells 
are not intimately mixed with the urine, and do not appear as 
washed-out corpuscles, it may indicate that their origin has 
been from the bladder or the urethra, but these facts should 
be combined with the other manifestations before an absolute 
diagnosis can be made. 

Leukocytes. — Leukocytes in small numbers are found in 
the urine of healthy individuals, but when found in excessive 
amounts, indicate some disease of the genito-urinary tract. 
They may be derived from the urethra, bladder, ureter, pelvis, 
or from the kidney itself. When found in great numbers, they 
frequently indicate cystitis ; when they are found as a result of 
inflammation of the pelvis or ureter, they appear in the urine 
in a considerable quantity, and, as a rule, in disease of the kid- 
ney substance itself a smaller number is found. Leukocytes 



EXAMINATION OF THE URINE. l6l 

in the urinary sediment are quite easily recognized. The proto- 
plasm of these cells frequently show degenerative changes ; 
their outline may be quite irregular ; the lobed nucleus is some- 
times obscured, but on the addition of a small amount of acetic 
acid it can be seen. When pus is found in the urine, the con- 
dition is known as pyuria ; when it is found in the urine in 
large amounts, it frequently deposits itself as a white sediment 
at the bottom of the vessel in which it is contained. This sedi- 
ment often resembles that produced by amorphous phosphate 
of lime. Phosphates, however, are dissolved on the addition 
of acid, while pus is not. 

Casts. — Tube-casts are said to be molds of the uriniferous 
tubules, produced either by substances in the lumen of the 
tubules without marked disease of the epithelial cells or by 
substance resulting from degeneration or coalescence of cells 
lining the tubules or contained in them. In the latter instance 
when formed from epithelium they are really not molds of the 
tubules themselves, but of their basement membrane. Casts 
are nearly always indicative of kidney lesion, but certain forms 
of them have been found in the urine of healthy individuals or 
after slight toxic influences. They are usually found in urine 
that contains albumin, but may be discovered when the urine 
is not albuminous. Different varieties of casts indicate par- 
ticular kidney lesions. As previously mentioned, casts may 
be formed as a result of coalescence or degeneration of the 
cells or to the exudation of these cells or, perhaps, as a result 
of the infiltration of materials into the tubules. We therefore 
divide them into three groups : (i) Those formed by coales- 
cence of cells ; (2) those due to degeneration ; (3) those due 
to some substance infiltrated into the lumen of the tubules 
either by an exudation from the epithelial cells or an infiltra- 
tion from the blood. 

Casts Due to Coalescence. — (a) Those formed by groups 
of epithelial cells, called epithelial casts ; (b) those formed by 
red blood-corpuscles, called blood-casts ; (c) those formed by 
leukocytes, called pus-casts ; (d) those formed by bacteria, 
called bacterial casts. 

Casts Due to Degeneration of Cells. — (a) Those due to 
granular degeneration, called granular casts ; (b) those due to 
fatty degeneration, called fatty casts ; (c) those due to waxy 
disease, called waxy casts. (It is doubted whether these are 
due to degeneration or to infiltration of some substance into 
the tubule without marked change of the epithelial cells.) 
11 



1 62 LABORATORY METHODS. 

Casts Due to Infiltration. — (a) Those probably due to 
an excretion of a hyaline material, called hyaline casts ; (b) 
long ribbon-like cylinders, probably produced in a similar 
manner to the hyaline casts, called cylindroids ; (c) unorgan- 
ized casts, produced by the infiltration of .crystalline or amor- 
phous substances into the tubule, the most common of these 
being casts of urates. 

Epithelial casts are always significant of a kidney lesion. 
Blood-casts are found in acute parenchymatous inflammation 
or conditions in which the renal tubules become filled with 
red blood-corpuscles. Pus-casts also originate in conditions 
similar to the formation of blood-casts. Bacterial casts, par- 
ticularly those composed of micrococci, are indicative of acute 
inflammation of the kidney, such as pyelonephritis. They 
may resemble granular casts, but differ from them in that 
they resist strong alkalies or acids. Granular casts may be 
composed either of coarse or fine particles. They are pale- 
gray or reddish-yellow in color, with irregular or wavy 
margins, the ends rounded and usually concave. Leuko- 
cytes, epithelial cells, and red blood-cells may be found ad- 
herent to these casts ; they are indicative of nephritis. Fatty 
casts signify subacute or chronic lesions of the kidney ; they 
result from fatty degeneration of the epithelial cells lining the 
tubules. Granular casts are frequently found to contain fat 
globules, and needles of fatty acids may also beset these casts. 
Under the microscope waxy casts appear as refractive, hom- 
ogeneous cylinders ; they are usually larger than other forms 
of casts ; epithelium and red and white corpuscles may be found 
adherent to the surface. They are found in acute and chronic 
forms of nephritis, and in amyloid disease. They may give 
the reaction for amyloid material, but this is by no means 
constant. Hyaline casts as well as cylindroids probably result 
from the exudation or secretion of a material from the epi- 
thelial cells lining the tubules. The hyaline casts often con- 
tain upon their surface epithelial cells, leukocytes, red blood- 
corpuscles, and sometimes urates, oxalate of lime crystals, 
and bacteria. These casts have been found in the urine of 
healthy individuals as well as in the urine of patients afflicted 
with various forms of renal disease ; they are, therefore, of 
little diagnostic value unless associated with other urinary 
findings, or when coated with epithelial cells, granular material, 
fat, leukocytes, or red blood-corpuscles. Cylindroids appear 
in ribbon-like cylinders. They are not indicative of kidney 



Plate II. 





Blood casts (some composed of disin- 
tegrated red blood-cells). 



a. Squamous epithelium from the urine. 
b. Epithelial casts. 




Hyaline casts. 



Coarse and fine granular casts. 




Cylindroids. 



Waxy casts. 



EXAMINATION OF THE URINE. 1 63 

lesions, and are found in normal as well as abnormal urine. 
Unorganized casts are most commonly formed from urates. 
They are generally found in gout and renal congestion. They 
are of little significance. 

Method of Examination for Casts. — The urinary sediment 
is obtained either by allowing it to stand for several hours or 
by the centrifuge. The sediment is placed upon a slide, and 
a cover-glass put upon it. Most forms of casts are easily 
recognized by microscopic examination. The hyaline casts 
are sometimes more readily demonstrated by staining with 
Lugol's solution. 

Spermatozoa. — These are found in the urine of men after 
coitus, masturbation, and emissions. It must be remembered 
that they occur in the urine of women directly after coitus. 
This is often of medicolegal value, as in cases of suspected 
rape. They appear as elongated bodies, measuring about 50 
microns in length ; the head occupies about 4 or 5 microns, 
and is oval in shape ; the remaining portion of the body has a 
tail-like elongation. 

Parasites. — Occasionally echinococcus hooklets, distoma 
haematobium (the eggs of this parasite), and the embryo of the 
filaria sanguinis hominis may be present in the urine. The 
oxyuris vermicularis and trichomonas vaginalis may find their 
way into the urine from the vagina. Various forms of bac- 
teria are occasionally found, such as the bacillus typhosus, 
the bacillus of tuberculosis, the streptococcus pyogenes, the 
diplococcus of gonorrhea, the pneumococcus, the bacillus of 
glanders, the ray fungus, and other micro-organisms. The 
appearance of tubercle bacilli in the urine signifies tuberculosis 
of some part of the genito -urinary tract. They may be con- 
founded with the smegma bacillus, which is sometimes found in 
the urine, and to avoid error it is best to use the catheter in 
securing the urine. The urinary sediment that contains 
tubercle bacilli should be examined in the same manner as 
sputum that contains this organism. (For points of differen- 
tiation between the tubercle bacillus and the smegma bacillus, 
see the chapter on Bacteriology.) 

Unorganized Sediments. 

Uric Acid. — This occurs in the urine in crystals of a red or 
reddish-yellow color. They vary in size and frequently re- 
semble whet-stone or sometimes rhombic plates, and are found 
in acid urine. They may be dissolved on the addition of 



164 LABORATORY METHODS. 

caustic soda or potash. This test is usually unnecessary, as 
their color is quite characteristic. 

Urates of Soda and Lime. — Amorphous urates are fre- 
quently found in acid urine as a brick-dust sediment. The 
color of this sediment may, however, be lighter when the 
specific gravity is low. Under the microscope they appear as 
fine granules, sometimes in the form of casts. These fine 
particles can in no way be differentiated under the microscope 
from other fine granular matter, and it is therefore necessary 
to apply chemical tests for their determination. They are dis- 
solved on the addition of acetic acid, or by the application of 
heat. The murexid test may be employed for the detection 
of uric acid, a small amount of the sediment after drying is 
placed upon a porcelain plate, and a few drops of nitric acid 
are added, which dissolves it ; the solution is then carefully 
evaporated to dryness. A few drops of liquor of ammonia 
are then added, and when uric acid is present a purple color 
is developed. 

Oxalate of Lime Crystals. — These crystals are found in 
acid urine after partaking of certain fruits and vegetables, such 
as apples, pears, tomatoes, beans, asparagus, etc., these sub- 
stances containing a large amount of oxalic acid. The condi- 
tion is also met with in hypochondriasis, diabetes mellitus, 
catarrhal icterus, neurasthenia, and sometimes in other nervous 
diseases. They also occur in tuberculosis and cancer. In 
health a few oxalate of lime crystals may be found in the 
urine, particularly after the ingestion of the foods mentioned 
above. When oxalates appear in the urine in large amounts 
the condition is known as oxaluria. The crystals of oxalate 
of lime appear as transparent, refracting octahedra, or dumb- 
bell crystals. They are soluble in hydrochloric acid, and 
insoluble in acetic acid. 

Bilirubin and Hematoidin Crystals. — Bilirubin. — These 
may appear in acid urine as a crystalline or amorphous sub- 
stance. In the crystalline form they appear either as needles, 
which are usually in clusters, or as rhombic plates. They are 
of a yellow or red color. By the application of nitric acid a 
green margin forms around them, and they are soluble in 
caustic potash. They have been found in the urine of those 
affected by jaundice. 

Hematoidin. — This substance closely resembles bilirubin. 
When found in the urine it usually indicates some preceding 
hemorrhage in the urinary tract. Hematoidin may be dis- 



EXAMINATION OF THE URINE. 1 65 

tinguished from bilirubin in that chemically it is insoluble in 
caustic potash, and on the addition of nitric acid a temporary 
blue color is developed. 

Ammonia-Magnesium Phosphate, or Triple Phosphate. 
— This is found in weakly acid or more commonly in alkaline 
urine. These crystals appear as rhombic prisms or coffin-lid 
crystals. They are colorless and usually of large size. On 
the addition of acetic acid they are soluble. When they are 
found in the urine in large numbers the condition is known as 
pliospJiatiwia. 

Basic Phosphate of Magnesium. — These crystals may be 
found in feebly acid or alkaline urine, and appear as elongated 
rhombic plates, and are soluble in acetic acid. 

Phosphate of Calcium. — When this substance is found in 
alkaline urine it appears as amorphous grains, which are 
soluble in acetic acid, but not by heat. W T hen it appears in 
urine having a neutral reaction wedge-shaped prisms are found 
which are often massed in clusters. They are dissolved on 
the addition of acetic acid. 

Sulphate of Calcium. — These are found in the urine 
as long needles or plates, being insoluble in ammonia and 
acids. They are of little clinical significance, and are rarely 
present in the urine. Amorphous deposits of this substance 
are sometimes encountered. 

Cystin. — These crystals appear in acid urine as six-sided 
plates. They are insoluble in acetic acid, but quite soluble in 
ammonia. They are of clinical significance, since they occa- 
sionally give rise to calculi. 

Leucin and Tyrosin. — These substances are usually found 
associated. 

Leucin appears in acid urine in the form of small spheres. 

Tyrosin. — This appears as fine needles which are grouped 
in bundles, sometimes called "Tyrosin sheaves." It is solu- 
ble in ammonia and hydrochloric acid, but insoluble in acetic 
acid. These substances are never found in normal urine. 
They are said to be due to degenerative changes of albu- 
minoid products. They occur in acute yellow atrophy of 
the liver, phosphorus poisoning, and some of the infectious 
diseases, particularly enteric fever and variola. They have 
also been noted in leukemia and pernicious anemia. 

Urate of Ammonia. — This substance appears in urine in 
the form of brownish balls, over the surface of which fine 
needles project, and they are commonly known as " hedge- 



1 66 LABORATORY METHODS. 

hog crystals." They appear in urine having an alkaline reac- 
tion, and are dissolved in hydrochloric and acetic acids. 

Cholesterin. — Crystals of cholesterin appear in alkaline 
urine as plates or scaly particles. They are very rarely found 
in the urine, but have been met with in cystitis. 

Urea. — Urea is increased in fevers, also after the crisis in 
pneumonia, after the ingestion of large amounts of albuminous 
food, also in diabetes, and after exertion. It is diminished in 
nephritis and in acute yellow atrophy of the liver, in wasting 
diseases and cachexia, especially when accompanied by dropsy, 
and usually in starvation. 

Test. — Fowler's hypochlorite method is based upon the 
fact that after decomposition of urine by hypochlorites a 
decrease in the specific gravity will be noted. Every degree 
lost in specific gravity corresponds to 0.77 of if . The 
process is as follows : Mix one volume of urine and seven 
volumes of hypochlorite solution (Labarraque's solution of 
chlorinated soda, U. S. P.). Before mixing this solution ascer- 
tain the specific gravity of the one volume of urine. Find the 
specific gravity of the Labarraque's solution and multiply the 
result by 7. Add the specific gravity of Labarraque's solution 
and the specific gravity of the urine and divide by 8, which is 
the specific gravity of the mixture. After two hours, decom- 
position of the urine is complete, and the specific gravity of the 
mixture is now ascertained. Determine the difference in spe- 
cific gravity before and after decomposition and multiply by 
0.77, and the result is the percentage of urea. 

Chlorid of Sodium. — The quantity of chlorids is increased 
during the resorption of exudates and transudates, in intermit- 
tent fever (from the destruction of red corpuscles). The quan- 
tity is decreased in febrile diseases, particularly in croupous 
pneumonia during the stage of consolidation of the lung, also 
in nephritis and wasting diseases. 



EXAMINATION OF THE FECES. 

In an examination of the feces the frequency with which 
the stools are passed and the accompanying symptoms must 
be noted. The stools must be examined as to quantity, con- 
sistency, form, color, and odor, and as to their macroscopic 
and microscopic appearance. 



Plate III. 





Uric acid crystals. 



Calcium oxalate crystals. 




Triple phosphate crystals. 



Ammonium urate crystals. 




a. Cholesterin crystals, b. Cystin 
crystals. 



Leucin and tyrosin crystals. 



EXAMINATION OF THE FECES. 1 67 

Under normal circumstances the frequency of the intestinal 
discharges varies greatly in individual cases. Nursing children 
have from three to four movements a day, and under normal 
circumstances an adult has from one to two movements in the 
course of twenty-four hours, although two or three movements 
is not incompatible with health if the person experience no 
inconvenience. Constipation or, as it is called pathologically, 
obstipation, is the condition opposite to looseness or diarrhea. 
Under ordinary conditions it may be stated that the frequency 
of the discharges is particularly connected with the quantity 
of food taken ; therefore, a person who is fasting will be con- 
stipated. Even the grade of the food has an effect upon the 
frequency of the intestinal discharges, but if the food pass 
rapidly through the intestinal canal, diarrhea may be pro- 
duced. 

Diarrhea. — Diarrhea is a most important symptom of 
intestinal catarrh. It may be due to cold and exposure, or 
it may result from infection, as in the acute infectious diseases 
(enteric fever, dysentery), or it may be due to errors of diet. 
Some drugs and poisons produce diarrhea, such as arsenic, 
mercury, etc. In cases in which the fluidity of the intes- 
tinal contents is increased diarrhea is apt to be an important 
symptom. 

Constipation. — This is of diagnostic significance in peri- 
tonitis and in severe obstruction, as in stenosis of the intestine, 
fecal accumulations, intussusception, strangulation and invagi- 
nation of the intestine, from tumors compressing the intestine, 
from constrictions, scars, or new formations in the intestinal 
wall, or from peritoneal exudations. In some conditions con- 
stipation may alternate with diarrhea, as in chronic peritonitis. 
Pain is present with the stools in inflammatory conditions of 
the intestine. Usually, severe pain occurs in inflammation of 
the lower portions of the rectum, in fissure, and abscess near 
the anus. Syphilitic disease and malignant affection of the 
rectum are always characterized by severe pain. Occa- 
sionally, severe pain is due to the presence of hemorrhoids. 
Painful straining at stool is known as tenesmus. Involuntary 
evacuations occur in any condition in which the cerebral func- 
tions are interfered with ; they may occur in paralysis, and 
particularly in diseases of the spinal cord. 

Macroscopic Examination of the Feces. — Amount. — The 
amount of feces passed by the normal individual in twenty- 
four hours varies between 120 and 180 grams, 75 <f of which 



1 68 LABORATORY METHODS. 

is made up of fluid and 25 ^ of solid substances. On a meat 
diet the normal quantity of feces is reduced in amount, being 
increased by starchy and vegetable diets. The amount of 
feces per day is greatly increased in some diseases ; thus, in 
Asiatic cholera 5000 grams in twenty-four hours have been 
noted. 

Color. — The normal color of the feces is a yellowish-brown 
or brown, the color being produced by urobilin, hydrobiliru- 
bin, or stercobilin. The feces of infants show a light-yellow 
color. Spinach and cabbage produce a greenish appearance. 
Iron, bismuth, and manganate cause a greenish-black color. 
Occasionally, after the use of the iodids in large amounts, 
bluish particles will be noted in the stools ; from absence of 
bile in the feces they are of a light-gray color. When large 
transudations of serous material enter into the bowel, " rice- 
water " discharges are observed; these are characteristic of 
Asiatic cholera, and are occasionally encountered in cholera 
nostras. If blood be present in the stool, it will have a red- 
dish-brown or black color ; and if it has been retained for 
some time, it frequently becomes tarry in appearance. 

Reaction. — The reaction of the feces is, in the majority of 
cases, neutral or alkaline. Upon an absolutely vegetable diet 
an acid reaction may be encountered, due to fatty, acetic, and 
butyric acids. Occasionally, in children (nurslings) the stool 
is slightly acid. 

Consistence. — Normally, the stool may be firm or slightly 
mushy, although the form rarely has an independent value. 
Band-like, flat scybala may indicate stenosis of the bowel. 

Odor. — In infants a slightly sour odor is normal. In gan- 
grenous discharges cadaverous, foul odors are encountered ; 
this also occurs in dysenteric and syphilitic ulceration of the 
rectum. 

Character of the Stools. — Mucous Stools. — When appre- 
ciable quantities of mucus are present in the evacuations, it 
shows a catarrhal condition of the mucous membrane of the 
intestine. In acute intestinal catarrh an abundant admixture 
of mucus, with thin stools, occurs. The same condition is 
likely to be present in catarrhal dysentery. Not every small, 
slimy particle should be regarded as mucus in the stool. 

Fatty Stools. — This shows a slightly glistening and greasy 
appearance, and if large quantities of fat be present, it may 
even be whitish or clay-like. This sometimes occurs in dis- 
ease of the pancreas and in some forms of diabetes mellitus. 



EXAMINATION OF THE FECES. 1 69 

Bloody Stools. — These vary in appearance. If the blood 
has been thrown out in large amounts and quickly passed, it 
is apt to be bright-red in color, whereas if retained a long 
time in the bowel, it is dark, clotted, and tarry. Blood may 
result from bleeding hemorrhoids. If the blood is intimately 
mixed with the feces, it is either from the stomach or from the 
small intestine. 

Purulent Stools. — Pus may occur in the stools from the 
rupture of an abscess anywhere in the intestinal tract. It is 
often found in inflammatory disease of the rectum. Pus may 
be present from dysenteiy, and from catarrhal, syphilitic, or 
carcinomatous ulcers of the large intestine. 

Gall-stones and Enteroliths. — Gall-stones are noted in 
the stools, having found their way through the common bile- 
duct into the duodenum. When gall-stones are searched for, 
the stool must be passed through a sieve. If it is formed or 
mushy, it must be broken up by pouring" water upon it. The 
gall-stone is easily recognized by its shiny appearance, smooth 
surface, and irregular outline, being faceted. Occasionally, 
after the eating of fruits, particularly pears, small concretions 
may be passed in the stool, which may be mistaken for gall- 
stones ; they do not, however, give the characteristic reaction 
for those substances. 

Solid portions of the feces, or undigested food, or concre- 
tions are called enteroliths. These are most frequently about 
the size of a cherry-stone, but occasionally are very much 
larger. 

Shreds of Tissue and Fibrinous Casts. — Sloughs of 
necrotic tissue resulting from ulceration are not infrequently 
found in the stools. Sometimes pieces of new formations, 
particularly from carcinoma, make their appearance in the 
feces. Fibrinous casts and shreds of mucus are encountered, 
especially in the course of dysentery. The shreds of fibrin 
may be mistaken for worms, but careful examination will 
reveal their identity. 

The animal parasites infesting the intestinal canal, and which 
are sometimes discharged in the feces, are described in the 
chapter on Animal Parasites. 

Microscopic Examination of the Feces.— A small amount 
of the feces is mixed with distilled water or a weak solution 
of sodium chlorid, the solid portions being carefully broken 
into small particles. A little of this mixture is placed upon a 
slide and a cover-glass laid upon it, or a few drops of the mix- 



I^O LABORATORY METHODS. 

ture are placed upon a cover-glass and this gently heated until 
dry, fixed by passing through a flame, and then stained. By 
the latter mode of procedure various forms of epithelium, 
leukocytes, red blood-cells, and bacteria are demonstrated. By 
the former method crystalline substances and various cells can 
be examined. Under the microscope various forms of un- 
digested material, such as fat, starch granules, muscle-fiber, 
and other substances, can be investigated. For examination 
of the ameba coli it is necessary to procure the fresh dejec- 
tions, the examination being conducted upon a warm stage. 

Red BIood=celIs. — These are detected upon microscopic 
examination. It sometimes happens in feces deeply stained 
with blood that it is difficult, or impossible, to find red blood- 
cells, but in such conditions crystals of hematoidin are found. 

Leukocytes. — In suppurative conditions of the alimentary 
canal, a great number of leukocytes are encountered in the 
feces. This is particularly so when ulceration exists. In the 
normal feces leukocytes are rarely if ever seen. 

Epithelium. — In the feces during health epithelium is con- 
stantly present, but when large numbers of these cells appear, 
it is indicative of an intestinal lesion, particularly catarrhal in- 
flammation. Various forms of epithelial cells are met with, 
and they often show degenerative changes. 

Bacteria in the Feces. — Bacteria are always found in the 
feces in great numbers. Many varieties have been isolated, 
the most common being the bacillus coli communis, the bacillus 
typhosus, the spirillum of Asiatic cholera, the bacillus of 
tuberculosis, the spirillum of Finkler and Prior, the staphylo- 
coccus, the streptococcus, and others. 

The following crystals have been found in the feces : Am- 
moniomagnesium phosphate, Charcot crystals, fat crystals, 
oxalate of lime, sulphate of calcium, and others. 



PART L 

INFECTIOUS DISEASES. 



THE CONTINUED FEVERS, 



SIMPLE CONTINUED FEVER. 

Definition. — Simple continued fever is a fever of two or 
three days' duration, dependent upon many causes. It is 
rarely fatal in temperate climates and is not contagious. 

This is purely a symptomatic disease : it is not a substantive 
affection, and it is questioned by many pathologists whether 
such a disease actually exists. It is not an irritative fever, 
such as might occur from traumatism, nor is it due to the 
absorption of pus or other toxemias. 

Synonyms. — Febricula ; ephemera ; synocha ; ardent fever 
of the tropics. 

Etiology. — There is no specific cause. Extremes of tem- 
perature may be said to produce the disease, and it has been 
claimed that it results from the inhalation of sewer-gas. 

Overeating, mental and bodily fatigue, excitement, and vio- 
lent emotions are supposed to be causative factors. The dis- 
ease is more common in children than in adults. 

Symptoms. — The disease rarely begins with marked chill ; 
however, there may be slight chilly sensations ; lassitude may 
occur early ; and the temperature may rise to 103 F. ; some- 
times in children the temperature may be higher than this. 

The face is flushed (herpes facialis may occur); the pulse is 
rapid, full, and bounding ; headache, frequently pronounced, is 
present ; often the tongue is coated or furred ; and there is 
loss of appetite. The urine is scanty and highly colored, but 

171 



172 INFECTIOUS DISEASES. 

rarely contains albumin ; the bowels are usually constipated, 
but there may be diarrhea toward the close of the attack. 
The patient may either be restless and suffer from insomnia, or 
he may be dull and drowsy. The disease may terminate sud- 
denly by crisis, or, more rarely, by lysis. The duration of the 
attack is from a few hours to several days. When the disease 
occurs in the tropics, the symptoms are more intense, the 
temperature is much higher, the nervous symptoms are more 
pronounced, and the malady may be mistaken for sunstroke. 
Delirium and coma may occur, and the disease may terminate 
fatally. 

Diagnosis. — In the absence of inflammatory conditions and 
of traumatism, with the presence of the symptoms just enum- 
erated, especially in children, a diagnosis of simple continued 
fever may be made. 

Prognosis. — Invariably favorable, except in the severe forms 
in the tropics. 

Treatment. — This is purely symptomatic, very little medi- 
cine being necessary. Usually, all that is required is, at the 
onset, a mild purge of calomel, in fractional doses, followed 
by a saline. Water should be given in moderate amounts ; 
forced feeding is unnecessary, as the disease is a mild one and 
of short duration. Should the temperature become high and 
the nervous symptoms prominent, cold sponging or bathing 
may be beneficial. If the disease occurs in weak or debili- 
tated persons, stimulants— preferably alcohol — should be ad- 
ministered. 



INFLUENZA. 

Definition. — A contagious fever due to a specific cause, 
the bacillus of Pfeiffer, usually occurring in epidemics, char- 
acterized by pronounced catarrh of the mucous membranes, 
with marked debility, and showing a tendency to inflammatory 
complications. 

Synonyms. — Epidemic catarrhal fever ; la grippe. 

Etiology. — Predisposing Causes. — All races of mankind 
are susceptible, the disease occurring in every climate and at 
all seasons. Both sexes are affected, females, however, being 
more predisposed. One attack increases the liability to others. 
It is highly infectious and contagious. Epidemics commonly 
last from eight to nine weeks. Sporadic cases are liable to 
occur for a long time after the active epidemic has terminated. 



INFLUENZA. I 73 

The exciting cause is the bacillus of Pfeiffer, which is found 
in the nasal secretions, sputum, and blood. 

Incubation. — The period of incubation varies from a few 
hours to two or three days. 

Pathology. — There is no characteristic lesion. Catarrhal 
inflammation of the mucous membrane of the respiratory and 
digestive tract and bronchopneumonia and lobar pneumonia 
are frequently met with. The specific organism has been found 
in the lung, liver, spleen, kidney, lymph-glands, membranes 
of brain, and endocardium, giving rise to inflammatory condi- 
tions. (For method of detection of the bacillus see p. 118.) 

Symptoms. — Since the pandemic of 1 889-1 890, our knowl- 
edge of this disease has materially increased. The varieties and 
complexity of the symptomatology are so great that an accu- 
rate description of this disease is almost impossible. This has 
led to the classification and arrangement of different varieties, 
according to the prominence of certain symptoms. The dis- 
ease begins after a very short period of incubation, generally 
with no or with ill-defined prodromes, with a pronounced chill 
followed by fever. Only in exceptional instances does the 
disease run its course without chill and fever. The range of 
the temperature is atypical, running from 99 F. to 105 ° F., 
rarely above this. The fever generally reaches its acme in the 
first twenty-four hours ; the temperature may, however, rise 
stepwise, and reach its fastigium only after three or four days. 
The decline of the temperature also varies, the disease termi- 
nating by lysis or crisis ; in the greater number of cases, 
however, the disease may be said to terminate by a form of 
rapid lysis. During convalescence the temperature may be 
subnormal. The duration of uncomplicated cases is about 
from five to seven days. In general terms, the poison of 
influenza attacks the mucous membrane of the respiratory 
and digestive tracts. It must, however, be remembered that 
there are cases that show no catarrhal phenomena ; in fact, 
nothing but fever with rapid pulse, headache, and depression. 
The lungs may bear the brunt of the affection, although the 
digestive tract, the cerebrospinal system, or the heart may be 
the principal seat of the disease. This has led to the classifi- 
cation of four principal varieties: (1) The thoracic variety; 
(2) the cardiac variety ; (3) the gastro-intestinal variety ; 
(4) the nervous variety. 

All these varieties show catarrhal symptoms in common, 
save in those exceptional cases already alluded to. 



174 INFECTIOUS DISEASES. 

Then, following the chill and fever, there are pains in the 
limbs and back, sneezing, coughing (at first unproductive), in- 
jected conjunctivae, pronounced headache, commonly referred 
to the root of the nose or behind the eyes, occasional vomiting, 
and diarrhea. Epistaxis is rare. 

All these symptoms appear with extreme rapidity. Rashes 
occasionally occur, such as herpes, urticaria, or erythema. No 
matter how mild any of the preceding symptoms may be 
in an individual case, there are always great depression and 
weakness that are out of proportion to the intensity of all the 
other phenomena. This is characteristic of influenza. In the 
majority of cases early enlargement of the spleen may be ob- 
served. Cardiac asthenia is a prominent symptom, the pulse 
being rapid, weak, compressible, and sometimes intermittent. 
The urine is scanty, highly colored, and rarely contains albumin 
(toxic), generally without casts. 

Complications. — The complications in this disease are ex- 
tremely numerous. Respiratory complications are the most 
common : the so-called, and not well-understood, influenza 
pneumonias, bronchopneumonia, croupous pneumonia, and 
pleurisy, with and without effusion. Otitis media and compli- 
cations relating to the heart, gastro-intestinal tract, and nervous 
system occur. 

Sequels. — The more important sequels are those relating to 
the heart and lungs. Cardiac asthenia with an intermittent 
and irregular pulse has frequently been observed. Chronic 
bronchitis, emphysema, and tuberculosis result. Diabetes and 
neuralgia, especially of the fifth nerve, are frequent. Anemia, 
and* even pernicious anemia, have been known to follow this 
affection. 

Diagnosis. — The diagnosis depends upon the occurrence 
of an epidemic. The sudden onset, with chill and fever, the 
marked catarrhal phenomena, the peculiar headache, the 
intense depression, and the cessation of the symptoms in un- 
complicated cases in from five to seven days by rapid lysis or 
crisis are diagnostic. 

Prognosis. — In young, robust subjects almost invariably 
favorable. In the extremes of age, especially in the old suf- 
fering from chronic diseases, the prognosis is unfavorable. 

Treatment. — Rest in bed, even in the mildest cases; is im- 
perative. A laxative dose of calomel or a saline early is fol- 
lowed by good results, even in those cases in which diarrhea is 
present. For the pains, opium in some form is the most 



ENTERIC OR TYPHOID FEVER. 175 

reliable drug, and Dover's powder or minute doses of morphin 
are generally employed. The coal-tar products should not be 
administered on account of their depressing effects upon the 
heart. If given at all, they should be used cautiously and in 
very small doses. Diet is not important, as the disease is a 
brief one, but stimulation should be insisted upon from the 
onset, especially in old persons or in individuals suffering from 
some form of chronic ailment. 



ENTERIC OR TYPHOID FEVER. 

Definition. — An acute, specific, infectious disease of from 
twenty-one to twenty-eight days' duration, due to the bacillus 
typhosus ; it is characterized by fever of a typical range, with 
gastro-intestinal symptoms, a rose-colored rash, and nervous 
symptoms. The disease shows constant pathologic lesions. 

Synonyms. — Typhoid fever ; gastric fever ; nervous fever ; 
infantile remittent fever ; autumnal fever ; typhus abdominalis. 

Description. — This disease was first differentiated by Louis 
in 1829, before this time being usually confounded with typhus 
fever. 

Etiology. — Predisposing Causes. — The geographic distri- 
bution is wide, the disease prevailing in every country ; it is 
especially prevalent, however, in temperate climates. Autumn 
months particularly favor the development of enteric fever ; 
often the disease follows hot and dry seasons. The majority 
of the cases occur between the ages of fifteen and thirty. The 
sexes are equally affected. Unfavorable hygienic surroundings, 
such as infected drinking-water, food, sewage, and poor drain- 
age, predispose in susceptible individuals. Insects, especially 
the common house-fly, may be the carriers of the infective 
principle. One attack usually confers immunity. 

Exciting Cause — A bacillus discovered by Eberth, known 
as the bacillus typhosus. (For detection see p. 108.) 

Pathology. — The cadaveric rigidity is well marked, the 
body is emaciated, and the typical eruption (rose-colored spots) 
is not present. 

The bacillus, gaining entrance into the gastro-intestinal tract, 
finds its way through a rupture in the mucous membrane into 
the lymph-nodes of the submucosa, where inflammatory 
changes take place. The principal seat of the lesions is the 
lower part of the ileum, in Peyer's patches, but the solitary 
lymph-follicles of other parts of the intestinal tract may be 



176 INFECTIOUS DISEASES. 

affected. Lesions have been found in the esophagus, stomach, 
vermiform appendix, and not infrequently in the large intes- 
tine. 

For convenience of description the inflammatory changes 
may be divided into four stages, each lasting about a week : 
(1) The stage/ of infiltration ; (2) the stage of necrosis ; (3) the 
stage of ulceration ; (4) the stage of healing. 

The first stage, that of infiltration, may involve the whole or 
a part of the Peyer's patch. It is elevated, indurated, and of 
a gray color. Hyperemia may be noted around the infiltrated 
area. The surface of the infiltrated area is often irregular and 
contains darker areas, and is sometimes spoken of as the 
" shaven-beard " appearance. 



5 




Fig. 24. — Typhoid fever, showing necrosis of Peyer's patches and intense congestion of 
the bowel (modified from Kast and Rumpel). 



The swelling of the Peyer's patch is due to the inflamma- 
tory exudate. The area contains numerous polynuclear leu- 
kocytes and round cells, many of which result from the pro- 
liferation of the fixed connective-tissue elements. There may 
be some red cells in the perivascular tissues, and the bacillus 
typhosus is also present. The blood-vessels show marked 
dilatation. 

The infiltrated area rarely extends deeper than the muscular 
coat; in some instances, however, this is involved. The soli- 
tary lymph-follicles frequently reveal similar changes. 

The second stage, that of necrosis, is due to the cutting 
off of the blood supply to the involved area, and the action of 
a specific poison. As the necrotic substance is discharged the 



ENTERIC OR TYPHOID FEVER. \JJ 

ulcer is formed, giving rise to the next stage. The necrotic 
process sometimes involves the walls of the blood-vessels, and 
when the necrosed area is discharged, hemorrhage is pro- 
duced. The hemorrhage may be either open or concealed. 
If the ulceration be deep and the influence of the toxins upon 
the muscular coat of the bowel be pronounced, paralysis of the 
coats may take place ; this is often the cause of concealed 
hemorrhage. 

In the third stage, that of ulceration, the ulcer more or less . 
conforms to the Peyer's patch. It is oval or circular in out- 
line, the greater diameter being in the long axis of the intes- 
tine, opposite the mesenteric attachment. The floor is usually 
smooth, and formed by the muscular coat. Sometimes it is 
roughened, as necrotic tissue still adheres to the floor. 

The edges may be somewhat overhanging and elevated. 
The great resistance of the muscularis mucosae to the action 
of irritants gives rise to the overhanging- character. The pro- 
cess may extend deeper, so that the muscular coat becomes 
necrotic ; or in some cases the peritoneum may form the floor 
of the ulcer, and this may be involved, giving rise to perfora- 
tion, which may be either circular or oval (punched out), the 
size varying from that of a small opening to two centimeters in 
diameter. 

The perforation may be a slit-like opening, and results from 
the action of a peristaltic wave upon a scybalous mass lodging 
in the ulcerated area, the bowel becoming tense and the in- 
elastic floor of the ulcer rupturing. When perforation occurs, 
the peritoneum invariably becomes inflamed, general peritonitis 
and death often following. If adhesions of neighboring coils 
of intestines are formed, a localized process results : frequently 
an abscess. 

The fourth stage, that of healing or cicatrization, follows 
the stage of ulceration. Granulation tissue is formed, and 
finally the fully developed fibrous tissue, over which the epi- 
thelium ultimately spreads. The scar is smooth. It may be 
somewhat depressed, but does not show marked tendency of 
contraction ; therefore, strictures of the bowel are almost un- 
heard of in this disease. 

The mesenteric glands are enlarged in all cases of enteric 
fever. They are soft and friable, and rarely ulcerate. The 
spleen is enlarged in about 90% of the cases. The capsule 
is tense, and the splenic pulp is soft and friable ; in rare 
instances rupture has been found. 



178 INFECTIOUS DISEASES. 

Granular degeneration of the voluntary and involuntary 
muscles of the internal organs, especially of the heart, is 
present. Hyaline degeneration of blood-vessels has been 
noted. Catarrhal inflammation of the gastro-intestinal mucous 
membrane occurs. 

The specific organism has been found in the feces (rarely 
before from the tenth to the sixteenth day), in the urine, in 
the spleen, and in other internal organs. 

The constitutional manifestations are due largely to the 
typhotoxins. 

Period of Incubation. — This is from two to three weeks. 

Symptoms. — The onset of the disease is insidious, and is 
preceded by prodromes, these consisting of malaise, vague 
pains in the limbs and back, headache, epistaxis, and slight 
evening fever. These symptoms continue until the patient is 
compelled to remain in bed. Diarrhea may be present, or 
may be easily invoked by a mild laxative. It is convenient to 
divide the symptomatology into periods of weeks, correspond- 
ing to the pathologic changes. 

First Week — At the end of the period of prodromes, 
which may be variable, the disease may be ushered in by 
chilliness or, rarely, by a distinct rigor. The pupils are di- 
lated, appetite is lost, and the tongue is covered by a dry, 
white fur, and its edges and tip are red. Diarrhea continues ; 
headache is increased, especially at night ; the pulse is fre- 
quent, and its volume is good, but later it becomes dicrotic. 
The temperature is characterized by a gradual rise, being 
higher each evening by about a degree and a half, until the 
fifth or seventh day, when the fastigium is reached. 

Toward the end of the week some tympanites occurs, and 
at this time a few scattered rales may be heard posteriorly 
over the chest. There is usually pallor of the face, with 
flushing of cheeks. The urine shows the changes of febrile 
conditions. At the end of the first week the spleen is perhaps 
slightly enlarged, and the characteristic eruption may be 
noticed. 

Second Week. — The symptoms just described now become 
aggravated, with the exception of headache, which commonly 
disappears. The eruption, if not previously noticeable, now 
shows itself, perhaps on the abdomen, chest, or back, but 
rarely appears upon the extremities, and exceptionally upon 
the face. It consists of slightly elevated, rose-colored spots, 
from one to four millimeters in diameter, disappearing on 



ENTERIC OR TYPHOID FEVER. 1 79 

pressure, and reappearing when the pressure is relaxed. They 
appear in successive crops, which last from two to three days. 
The spleen is now found to be enlarged ; the fever high and 
subcontinuous in type ; the pulse weaker, from 90 to 1 20, and 
dicrotic. Occasionally, the hearing is dull. There may be 
low, muttering delirium. The intestinal symptoms are more 
pronounced than during the first week. In favorable cases 
defervescence may set in. 

Third Week. — The symptoms become more severe ; as- 
thenia and emaciation are pronounced ; fresh crops of the 
eruption may appear. At this time, which corresponds to the 
stage of ulceration, such complications as hemorrhage and 
perforation may be noticed. The temperature-curve becomes 
remittent in type ; the pulse is feeble, and the first sound of 
the heart may be inaudible. Among the symptoms are ex- 
cessive sweating and sudamina ; dry and coated tongue, with 
brownish fur upon it ; collection of sordes upon the teeth ; 
and probably involuntary evacuation of urine and feces. The 
delirium now becomes more marked and perhaps violent in 
character, or there may be stupor, coma, carphology, or sub- 
sultus tendinum. 

Fourth Week. — The symptoms ameliorate, the temperature 
becoming intermittent and the sordes disappearing as the 
tongue clears and the spleen contracts to its normal size. 
The urine increases in amount, and if there has been presence 
of albumin, this disappears. The mind clears, and great hun- 
ger develops. Convalescence is protracted, but may be inter- 
rupted by complications, relapses, and sequels. 

The temperature during convalescence is very unstable, 
running a subnormal course ; recrudescences may occur 
through constipation, excitement, improper food, etc. 

Special Symptoms. — Temperature. — The temperature 
rises, gradually reaching its fastigium in from five to seven 
days. During the second week the course of the temperature 
is subcontinuous, falling each morning a degree or a degree 
and a half, and rising each evening to the same height as on 
the previous evening. This continues another week. During 
the third week there are greater remissions in the morning, 
the temperature assuming a decided remittent type until the 
fourth week, when it falls to or below the normal, giving an 
intermittent type. During convalescence the temperature is fre- 
quently subnormal, being labile and easily disturbed. Indis- 
cretions in diet, visits of friends, excitement, mental emotions, 



i8o 



INFECTIOUS DISEASES. 



and constipation frequently produce a rise, called a recru- 
descence. 

Departure from the type may occur. There may be a sud- 
den rise at the onset, beginning with a chill, running a brief 
course, and ending by crisis. This is known as the abortive 
form, and takes place particularly in the enteric fever of chil- 
dren, showing a decided remittent range, thus giving rise to 
one of the synonyms called " infantile remittent fever." It is 
common for the typical curve to be interrupted by intercurrent 
diseases or complications. Hyperpyrexia, called the pre- 




Fig. 25. — Temperature-curve in enteric fever. 



agonistic rise, occasionally occurs, especially in fatal cases, 
just before death. The fever-curve of relapse corresponds to 
the original attack, but the fastigium is more quickly reached, 
defervescence taking place sooner. 

Circulatory System. — As is usual in febrile diseases, the 
pulse frequency corresponds to the intensity of the fever, 
although this disease is one of relatively slow pulse. At the 
onset the pulse is of full volume and the tension is low, and 
soon in the process of the disease becomes dicrotic ; this is an 
important diagnostic phenomenon in enteric fever. The pulse 



ENTERIC OR TYPHOID FEVER. lb I 

frequency in uncomplicated cases is from 90 to 100, but in 
severe cases it may be accelerated. A pulse-rate above 1 10 is 
of unfavorable prognostic omen. There are changes in the 
heart muscle corresponding with those of the pulse. In severe 
cases the first sound of the heart becomes feeble or may be 
inaudible. Endocarditis and pericarditis, as complications, are 
of rare occurrence. Venous thrombosis, especially of the 
crural vein, often occurs during convalescence. 

Blood. — Leukocytosis is absent in this disease, but any in- 
flammatory complications, particularly peritonitis, gives rise to 
it. As the fever progresses anemia becomes more pronounced, 
being of a chlorotic type ; this continues into convalescence 
and gives rise to " post-typhoid anemia." The Widal reaction 
is present in about 95 fy of the cases. (See p. 109.) 

Respiratory System. — Epistaxis is an early and a common 
symptom ; some degree of bronchitis is commonly met with, 
and in severe cases, from continuity of structure, the catarrhal 
process may extend downward, giving rise to bronchopneu- 
monia. When coma occurs, food that is retained in the mouth 
and not introduced into its proper channel may get into the 
trachea, set up inflammatory changes, and give rise to a form 
of pneumonia known as deglutition inhalation, or insufflation 
pneumonia. This complication is one of extreme gravity. 
Croupous pneumonia also occurs as a complication. Pleurisy 
and empyema are occasionally met with. 

Digestive System. — Nausea and vomiting may take place 
at the onset and continue for a few days. Epigastric pain, 
chiefly referred to the right iliac fossa, frequently occurs. 
Diarrhea is a characteristic symptom, and may be present from 
the first and continue throughout the disease, even into con- 
valescence. Constipation is present in some cases, but diar- 
rhea is easily invoked by mild laxatives. Stools may vary 
from two or three to a dozen or more in twenty-four hours. 
They are thin and brownish in color at first, but soon become 
yellowish, and are known as "pea-soup" stools. The tongue 
is characteristic : at first there is a slight whitish coat, appear- 
ing posteriorly, while the edges and tip are red ; later the 
tongue becomes dry and the coating yellow and brown ; at this 
stage it may also show fissures. Tympanites is common. 
Appendicitis may be a complication. 

Hemorrhage. — Hemorrhage from the bowel is an important 
complication, and is found in about 5 % of the cases, occurring 
late in the second or early in the third week, and varying from 



152 INFECTIOUS DISEASES. 

a few drops to a quart or more. This gives rise to character- 
istic symptoms. Sudden fall in temperature ; a rapid, run- 
ning pulse ; disappearance of nervous symptoms, such as 
delirium and coma ; increased respirations, commonly called 
"air-hunger"; and perhaps the appearance of blood in the 
stool, are the diagnostic criteria by which this complication is 
recognized. 

Concealed Hemorrhage. — If the blood does not appear in 
the stool with these symptoms, it is termed "concealed 
hemorrhage," and may be recognized by a sausage-shaped 
tumor in the right iliac fossa, which is dull or flat on per- 
cussion. 

Perforation. — With a sudden fall in the temperature, reach- 
ing the normal or subnormal point, accompanied by abdominal 
pain, rigidity of the abdominal muscles, a rapidly running 
pulse, and hurried respiration, a diagnosis of perforation 
should be made. This is present in from 2 to 3^ of the 
cases. 

General Peritonitis. — Frequently, following perforation, 
vomiting sets in ; abdominal pain becomes more intense and 
general, and leukocytosis is usually present. The abdomen 
is distended, the muscles are rigid and board-like, and the pulse 
is frequent and wiry. The temperature rises, flatus does not 
escape, and the lower border of liver dullness is obliterated ; 
these symptoms indicate general peritonitis. Nervous symp- 
toms are not marked. 

Liver and Ducts. — Recent investigation has shown that 
the bile is often infected with the bacillus typhosus, and thus 
may be the cause of relapse. Jaundice is rare and very fatal. 

Spleen. — The spleen is enlarged in 90^ of the cases, and 
reaches its maximum size some time in the course of the 
second week. 

Nervous Symptoms. — Headache is one of the early pro- 
dromes ; it is usually frontal, but may be general ; worse 
toward night, and subsides early in the second week. Som- 
nolence, drowsiness, apathy, delirium, dizziness, dullness of 
hearing and vision, twitching of the tendons, and in grave cases 
stupor, which passes into coma, take place. Dilatation of the 
pupils may also be referred to the nervous system. Convulsions 
are rare, and only occur when meningitis or other complications 
take place. 

Skin. — The rose spots constitute the specific eruption. 
They occur as scattered, pale-red, slightly elevated papules, 



ENTERIC OR TYPHOID FEVER. 1 83 

oval or irregularly circular in shape, and from one to four 
millimeters in diameter. They disappear on pressure and 
appear in successive crops, each individual crop having a 
duration of from two to three days. 

They appear upon the abdomen, the upper and lower por- 
tions of the chest, the thighs, the shoulder-blades, and, ex- 
ceptionally, upon the face. They are not very numerous as a 
rule, but may be abundant. A copious rash indicates a severe 
infection. The rash commonly appears at the end of the first 
or early in the second week, and continues throughout the 
disease, even into defervescence. Sudamina occur late : when 
sweating begins. Petechias are rare and of grave import. 
Herpes of the nose and lips takes place in some cases. A 
diffuse erythematous rash occasionally appears upon the face. 
Abscesses are complications. Furunculosis occurs in con- 
valescence. Bed-sores appear in certain cases. The hair 
falls out during convalescence. Occasionally a bluish rash may 
appear upon the abdomen, and does not disappear upon 
pressure. This is known as the " tache bleuatre," and indi- 
cates body-lice. Purulent inflammation of the middle ear is a 
common sequel. The "tache cerebral" is present in some 
cases. 

Urinary Apparatus. — The urine presents changes that 
accompany febrile diseases. The diazo-reaction is of some 
diagnostic importance. (See p. 159.) The toxicity of the urine 
is increased ; especially marked after systematic bathing. 

Relapse. — Relapses occur in from 3^ to 18 f of the 
cases, and at any time during the course of the disease, most 
generally during the period of defervescence. They are char- 
acterized by a return of all the symptoms ; the course, how- 
ever, is usually briefer than the original attack. Two, three, 
and even four relapses have been observed in a given case. 

Varieties. — 1. Abortive. The abortive form is of short 
duration, beginning abruptly by chill and ending by crisis. 2. 
Mild. The symptoms are slight, the temperature does not 
reach 103 F., the diarrhea is mild, the prostration is not 
great, and convalescence is rapid. 3. The ambulatory form — 
"walking typhoid" or "latent typhoid." Symptoms so mild 
or resistance so great that the patient does not take to bed. 
These cases often terminate fatally. 4. The apyrexial form. 
This form runs its course without fever. 5. Grave form. 
Symptoms severe and usually associated with subcutaneous or 
internal hemorrhages ; sometimes called the hemorrhagic 



184 INFECTIOUS DISEASES. 

form. 6. Infantile remittent fever. Enteric fever in chil- 
dren is a common occurrence, and is characterized by fever 
of a remittent type, is often abortive, and the characteristic 
eruption is often absent. 7. Enteric fever of the aged. This 
disease is rare after forty years of age, but old people are 
occasionally affected. The mortality is high. 

Intercurrent Diseases. — Cerebrospinal fever, malaria, tu- 
berculosis, and syphilis are the principal intercurrent affec- 
tions. 

Sequels. — These are extremely numerous. Otitis media is 
common. Alopecia occurs, but the hair in the majority of 
cases returns. Phlebitis, especially of the left leg, appears. 
It may take place in both legs. A form of insanity, mostly 
due to anemia of the brain, may develop, from which the 
patient recovers when the general nutrition improves. Dis- 
eases of the bones are not at all uncommon, and even 
abscesses may take place in which the Eberth bacillus may be 
found months or even years after the attack. Dislocations 
and fractures of the long bones also occur. 

Diagnosis. — This depends upon the occurrence of a pro- 
longed course of fever, with abdominal symptoms, enlargement 
of the spleen, rose spots, headache, diarrhea, nosebleed, 
dicrotic pulse, and some rales in the chest. If constipation is 
present, diarrhea may be easily invoked by a mild laxative. 
The temperature may range from 103 ° F. to 105 ° F. The 
Widal test is of value in diagnosis, especially in doubtful or 
obscure cases. Ehrlich's diazo-reaction is present in enteric 
fever, but also takes place in other affections. 

Differential Diagnosis — The diseases mostly resembling 
enteric fever at some stage in its course are influenza, estivo- 
autumnal malarial fever, acute miliary tuberculosis, cerebro- 
spinal fever, and ulcerative endocarditis. 

1. Uncomplicated influenza lasts from five to seven days, 
whereas enteric fever shows its most prominent symptoms 
only at the end of the first week. 

2. Estivo-autumnal uialarial fever often closely resembles 
enteric fever. By the examination of the blood malarial 
parasites differentiate these diseases. (See article on Malaria.) 

3. In acute miliary tuberculosis there is a history of previous 
cough or pleurisy. Temperature is more irregular, pulse is 
not dicrotic, rose spots are absent, pulmonary symptoms are 
more marked than abdominal, and examination of sputum, 
stools, and urine may show presence of tubercle bacilli. 



ENTERIC OR TYPHOID FEVER. 1 85 

4. Cerebrospinal fever may resemble enteric fever at its 
onset, but the absence of typical temperature, rose spots, and 
the greater preponderance of nervous symptoms, such as 
headache, retraction of the muscles of the back of the neck, 
and cerebral vomiting will usually disclose the true nature of 
the affection. 

5. In ulcerative endocarditis the previous history, presence 
of changeable endocardial murmurs, chill, fever, sweating, and 
leukocytosis are important differential points. 

Prognosis. — This depends in a great measure on treatment. 
The systematic cold-bath treatment of Brand has reduced the 
mortality to about 7 % . The earlier the treatment is instituted, 
the more favorable is the prognosis. The occurrence of 
severe complications is unfavorable. Fat subjects bear the 
disease badly. 

Treatment. — Prophylaxis. It is important to prevent new 
cases from developing, either from direct or indirect contact. 
Absolute destroying of the discharges and disinfection of the 
soiled linen must be carefully attended to. Chlorinated lime, 
commercial hydrochloric acid, and solutions of carbolic acid 
may be employed for disinfecting. Corrosive sublimate is less 
efficient, as it coagulates albuminous matter. 

Rest. — Rest in bed. 

Diet. — There should be an absolute liquid diet, milk, broths, 
etc. Fluids should be administered in liberal amounts ; alcohol 
forms no necessary routine in the treatment of this disease. 
It should be given in cases of great prostration and on the 
appearance of grave nervous symptoms. 

Routine Treatment. — A laxative dose of calomel should 
be given before the tenth day, never later. Specific treatment 
is of no avail. 

Method of Brand. — Systematic cold bathing should be 
resorted to as early as possible. When the temperature in 
the axilla reaches 10 if ° F., a cold bath is given and repeated 
every three hours, the water being at the temperature of about 
70 ° F. The patient should be immersed in the tub, the water 
covering all but the head. Then water of a lower temperature 
should be poured upon the patient's head, or a wet ice pack 
used. Gentle friction should be applied constantly by the 
attendants, and the patient should be encouraged to do like- 
wise. Do not rub the abdomen ! The duration of the bath is 
fifteen minutes. Some alcoholic stimulant should be adminis- 
tered to the patient before and after the bath. When the bath 



I 86 INFECTIOUS DISEASES. 

is finished, he should be lifted back to his bed and covered 
with woolen blankets. The temperature should be taken 
one-half hour afterward. Contraindications to the bath are 
hemorrhage and perforation. 

Intestinal Hemorrhage. — There should be absolute quiet 
and withholding of food for a time. Opium in some form 
should be given to its physiologic limit, ice-bags placed upon 
the abdomen, and the foot of the bed elevated. Hot-water 
bags may be applied to the extremities. 

Peritonitis. — Peritonitis also calls for the full administra- 
tion of opium and of ice-bags to the abdomen. In per- 
foration surgical interference should be solicited if diagnosti- 
cated early, otherwise this condition must also be treated with 
liberal doses of opium. 

Heart Failure. — Heart failure sometimes occurs in conva- 
lescence. The treatment is absolute quiet in the recumbent 
posture. Cardiac stimulants, such as alcohol and strychnin, 
should be freely administered. 

Constipation. — This may be relieved by enema and glycerin 
suppositories. Avoid purgatives. 

Tympanites. — Give alcohol freely. Apply turpentine stupes 
to the abdomen. Turpentine internally is of use. The bowel 
should not be perforated by hypodermic needle or other appli- 
ances. 

Management of Convalescence. — The process is long and 
tedious. Semisolid or solid food should not be administered 
before the evening temperature has been normal for at least 
one week. If the anemia is pronounced, iron, arsenic, cod- 
liver oil, and quinin are of use. 

TYPHUS FEVER. 

Definition. — A specific, infectious, contagious disease, 
occurring in epidemics, usually of short duration, — fourteen 
days, — characterized by marked nervous symptoms, a typical 
rash, and a high mortality. 

Synonyms. — True typhus ; petechial typhus ; ship fever ; 
jail fever ; spotted fever ; typhus exanthematicus. 

Etiology. — A disease of cold and temperate climates, 
occurring especially in the British Isles and in Southeastern 
Russia. This was the great fever of the past historic epoch. 
The disease is markedly contagious as well as infectious, 
although it is probable that the contagion is not carried to 



TYPHUS FEVER. 



187 



any great distance. It spreads through the atmosphere, and 
is carried by fomites. Overcrowding, filth, and scarcity of 
food favor its development. The largest number of cases 
occur between the ages of fifteen and twenty-five, although it 
may appear . in childhood and in old age. Both sexes are 
equally affected. The exciting cause is unknown ; no doubt, 
however, it is a specific germ. Several organisms have been 
described, but none is generally accepted. One attack confers 
immunity. 

Pathology. — There is no characteristic lesion. The post- 
mortem rigidity lasts but a short time. The typical eruption 




Fig. 26. — Temperature-curve in a case of typhus fever. 



persists. Spleen and liver are found enlarged, and the blood 
is profoundly altered, dark, and stains the tissues. No ulcers 
.are found in the intestinal tract. 

Period of Incubation. — The period of incubation is a vari- 
able one, but is generally estimated as being about fourteen 
days. 

Symptoms. — The prodromes are usually slight and often 
entirely absent, the disease beginning with a severe chill 
accompanied by nausea, vomiting, and epigastric pain. The 
temperature rises abruptly, and soon reaches 104 F. or 105 ° 



155 INFECTIOUS DISEASES. 

F., or even higher. The pulse frequency is increased, being 
over 100 a minute, hard, and not easily compressible. The 
patient has the sensations of an impending severe illness, be- 
comes weak, vertigo sets in, and soon delirium follows. There 
are deafness and tinnitus aurium. The face is reddened or 
turgid, the eyes are glassy, the pupils contracted, and the con- 
junctivae injected. A mousy odor exudes from the body. The 
tongue is coated with a grayish-yellow fur ; the lips are dry 
and cracked and bleed easily, and the teeth are covered with 
sordes. Anorexia is complete, but there is much thirst. The 
liver and spleen are painful upon palpation, and are now found 
to be enlarged. These symptoms continue for about five 
days, when the specific eruption appears. 

Eruption. — The characteristic eruption of typhus in its 
early stages closely resembles measles, and the term " measley 
eruption " is frequently applied to it. Macular spots of irreg- 
ular size and outline and of a dirty pinkish or reddish color 
characterize the exanthem. It appears first upon the chest 
and abdomen, and extends to the extremities, the face being 
rarely affected. It is particularly copious upon the extremi- 
ties, where it later in the disease becomes darker or petechial. 
Another eruption is also characteristic, and consists of marb- 
ling or mottling of the skin; hence the term " subcuticular 
mottling." This rash lasts throughout the disease and does 
not disappear in death. 

Delirium and subsultus tendinum appear early in the course 
of the disease, and the patient soon lapses into a comatose 
condition. 

The abdominal symptoms are not marked. Constipation is 
characteristic of this affection. Sometimes involuntary evacu- 
ations take place, from paralysis of the sphincters of the rec- 
tum and bladder. The pulse is rapid, — 120 to 140, — small, 
and soft. The respirations are frequent, — 40 to 60, — noisy, 
and blowing in character. As these symptoms occur, changes 
take place in the eruption, in the center of which purplish or 
bluish points appear (''true petechia"). 

The patient may now lie in a semi-unconscious or com- 
atose condition for some days. If recovery takes place on 
or about the fourteenth day of the disease, a sudden drop 
in the temperature occurs, — frequently five or six degrees, — 
with copious sweating, free diarrhea, or the passage of large 
quantities of urine. The temperature falls to normal or sub- 
normal, the pulse becomes slower and fuller and less frequent, 



TYPHUS FEVER. 1 89 

nervous symptoms entirely disappear, and the patient rapidly 
passes into convalescence. 

Urinary Symptoms. — The urine shows the usual charac- 
teristics of febrile urine. The quantity is lessened, the spe- 
cific gravity high, and there is abundance of solid material, 
such as phosphates, urates, and toxic albuminuria. 

Complications. — If this favorable issue does not take 
place, the patient remains in the comatose condition. Com- 
plications develop, particularly hypostatic congestion of the 
lungs, croupous pneumonia, pleurisy, pleurisy with effusion, 
and the patient may die from gangrene or from edema of the 
lungs. Relapses are extremely rare. 

Sequels. — Peripheral neuritis, thrombosis of the veins, 
parotid bubo, and otitis media occur as sequels. 

Diagnosis. — This is not difficult ; the sudden onset with 
high temperature, the appearance of the rash on or about the 
fifth day, the marked nervous symptoms, the contracted 
pupils, the early prostration, the history of the epidemic, are 
all characteristics of this disease. 

Differential Diagnosis. — The diseases which most closely 
resemble typhus fever are relapsing fever, measles, and enteric 
fever. The differential diagnosis between typhus and relaps- 
ing fever can readily be made by an examination of the blood. 
In relapsing fever, during the febrile stage the specific organ- 
ism, the spirillum of Obermeier, is found. The disease can 
be differentiated from measles by the absence of catarrhal 
symptoms, the sparsity of eruption of the face, and the 
severer nervous symptoms. The differential diagnosis be- 
tween typhus fever and enteric fever may be made from the 
greater predominance of intestinal symptoms in enteric fever, 
the typical temperature-curve, the eruption occurring later 
and disappearing upon pressure, and from the greater length 
of the disease. The Widal reaction is of great use in the 
differential diagnosis in obscure cases. 

Prognosis. — Typhus fever is a very serious affection, the 
average mortality being between 30% and 40^. Unfav- 
orable signs are a soft, compressible pulse above 120, hurried 
respirations, pinhole pupils, convulsions, muscular tremors, 
hiccup, and the presence of serious complications. 

Treatment. — The treatment is symptomatic. Prophylaxis 
is of the greatest importance. An abundant supply of good 
food, fresh air, and free ventilation are important. 

Stimulation is necessary on account of the severe prostra- 



I9O INFECTIOUS DISEASES. 

tion. If hyperpyrexia occurs, the cold bath should be re- 
sorted to. Strychnin may be necessary as a respiratory and 
cardiac stimulant. Complications must be treated as they 
arise. During convalescence the patient should be kept upon 
his back, and not allowed to assume an upright position too 
early, on account of the cardiac asthenia. Constipation should 
be relieved by enemata. Tonics should be administered. 

RELAPSING FEVER. 

Definition. — An acute, specific, infectious disease, markedly 
contagious, prevailing in epidemics and in times of famine. 
It is characterized by three stages : First, a febrile stage, 
lasting about seven days ; second, a period of apyrexia ; and 
third, a relapse on or about the fourteenth day, with the initial 
symptoms reappearing. This disease is due to the spirillum 
of Obermeier. 

Synonyms. — Spirillum fever ; famine fever ; and typhus 
recurrens. 

Etiology. — The disease is common in Ireland and in some 
parts of Europe. It is rare in this country. It occurs at all 
seasons of the year, and is more common in children and in 
early adult life, and is seldom found in persons after fifty. 
Sex and occupation are without influence. Famine is a pre- 
disposing cause. 

Exciting Cause. — Obermeier, in 1873, observed in the 
blood of patients suffering from this disease highly motile 
spiral filaments. These organisms have since been constantly 
found in the blood of patients suffering from relapsing fever. 
They have a corkscrew shape, and move with great rapidity 
in a rotary manner. They may adhere to the blood-corpuscles, 
but are occasionally found clumped or in masses. They do 
not occur during the period of apyrexia in the peripheral 
blood, but reappear again in the relapse. These micro-organ- 
isms have not been found in the discharges, in the saliva, or 
in the sweat, nor can they be cultivated outside of the body. 
Inoculation experiments have been successful. The organism 
has not been found after death'. (For description of the germ 
see p. 1 17.) 

Pathology. — The parasite finds access to the body in some 
manner not yet understood, and multiplies, giving rise to the 
characteristic phenomena of the attack. One attack does not 
confer immunity. 



RELAPSING FEVER. 



I 9 I 



Leukocytosis is common, but there are no constant ana- 
tomic lesions. Cadaveric rigidity is well marked, and the 
body is usually emaciated on account of the high temperature. 
The liver and spleen are enlarged. The heart is not changed. 
The lungs may show the appearance of bronchitis or broncho- 
pneumonia. 

Symptoms. — Incubation. — The period of incubation is 
from five to eight days. The onset is abrupt, with chill, frontal 
headache, pain in the back and limbs, and temperature rising 
to 104 F. The patient suffers from severe thirst and anorexia. 
The tongue is covered with a whitish fur, and the temperature 




Fig. 27. — Temperature-curve in a typical case of relapsing fever. 



may continue rising to 106 F., or even higher in the evening, 
with morning remission of a degree or two. Chilly sensations 
may continue, and sweating occurs. The respiration may be 
thirty a minute or even higher. Jaundice occurs in about 
75% of the cases. 

The urine may be stained with bile pigment ; tenderness is 
present over the liver and spleen, and these organs are found 
to be enlarged. No typical eruption occurs. Sleeplessness 
is usual ; the mind is clear, but delirium may ensue at the end 
of the attack. Crisis occurs about the seventh day, with pro- 



192 INFECTIOUS DISEASES. 

fuse sweating, temperature and respiration falling, and the 
pulse-rate rapidly decreasing from 130 to about 70. The 
tongue clears, and the patient may feel comfortable. Recovery 
is rapid. 

The second period, or period of apyrexia, lasts about seven 
days. The temperature, which may have been subnormal, 
rises in a day or two ; ravenous hunger develops and strength 
is speedily regained, when, on or about the fourteenth day 
from the beginning of the disease, the temperature rises again 
with all the symptoms of the initial attack. The relapse differs 
from the original attack in the fact that the fever, although it 
may be higher, is usually briefer. A second, third, or even a 
fourth relapse has been observed. Convalescence is slow and 
tedious, and some time elapses before the patient regains his 
normal condition. 

Complications and Sequels. — Bronchitis, pleurisy, bron- 
chopneumonia and croupous pneumonia, and edema of the 
lungs have been noticed. 

Diagnosis. — Depends upon the suddenness of the onset, 
the high febrile movement, the critical defervescence on or 
about the seventh day, the period of apyrexia, the absence of 
eruption, the relapse, and the presence in the blood of the 
specific organism. 

Differential Diagnosis. — The disease may be confounded 
with irregular types of malaria and typhus fever. The diag- 
nosis may readily be made between malaria and relapsing fever 
by a microscopic examination of the blood. 

The differential diagnosis between relasping fever and typhus 
fever may be made from the absence of the typical rash, the 
enlargement of the liver and spleen, and the finding of the 
specific organism in the blood. 

Prognosis. — This is favorable, the mortality being very low. 
Death ensues from complications. 

Treatment. — The treatment is purely symptomatic. No 
drug is known that will abort or prevent the relapse. Anti- 
pyretics are usually not required. For the pain in the epigas- 
trium and liver or spleen, cold or warm compresses and opium 
may be employed. Tonics should be given during conva- 
lescence. 



YELLOW FEVER. 193 

YELLOW FEVER. 

Definition. — An acute, specific, epidemic disease of short 
duration, occurring in tropic or subtropic countries. It is 
characterized by epigastric tenderness, albuminuria, the vomit- 
ing of black, altered blood, and by a yellow discoloration of 
the skin, due to the bacillus of Sanarelli. 

Synonyms. — Black vomit. Known as yellow fever in all 
languages. 

Etiology. — A disease of populous centers extending along 
the lines of travel. One attack usually confers immunity. 
All ages and both sexes are equally affected. The disease is 
endemic in the West Indies, parts of the Mediterranean coast, 
South America, and Africa. This is known as the focal zone. 
It is carried to the Gulf States and occasionally as far north 
as Virginia ; this is known as the perifocal zone. When it in- 
vades cities further north, it is known as the zone of accidental 
epidemics ; such places include New York, Philadelphia, and 
Boston. It is extremely rare above the fortieth parallel of 
latitude. 

Exciting Cause. — The bacillus of Sanarelli. (Seep. 120.) 

Period of Incubation. — Varies greatly, it may be from one 
to seven days. 

Pathology. — There is present marked jaundice. The liver 
shows marked fatty degeneration. The kidneys reveal paren- 
chymatous or fatty degeneration. In the stomach a black 
fluid is found ; the walls of this organ exhibit areas of hemor- 
rhage, and microscopic examination will show some fatty de- 
generation. The heart is flabby, and may also reveal fatty 
degeneration. 

Symptoms. — The disease usually consists of three well- 
defined stages : the period of onset, the calm, and the collapse. 
The disease begins with a chill or chilliness, followed by mus- 
cular pains, headache, and pains in the back. The tempera- 
ture rises rapidly to its maximum in twenty-four 'hours. It 
may reach 103 ° F. or 104 F. The pulse is usually from 70 
to 80 ; the face is flushed ; the eyes are clear and glistening, 
with some edema of the lids ; the expression is anxious. 
Nausea and vomiting are common. True albuminuria occurs 
early on the second day. Slight jaundice may be present at 
this time. There is pain in the epigastrium, and the bowels 
are constipated. It is characteristic of this disease that the 
pulse diminishes as the fever continues, so that bradycardia 
13 



194 INFECTIOUS DISEASES. 

may be a symptom of this disease. This stage lasts from 
three to five days, and is succeeded by the stage of calm. 
From this point on convalescence may be rapid and uninter- 
rupted, or the patient may pass into the third . stage. The 
calm rarely lasts longer than from twelve to twenty -four hours. 

In the stage of collapse all the initial symptoms return with 
greater severity. The pulse now becomes more rapid and the 
fever higher, although this is not a disease characterized by 
hyperpyrexia. Jaundice, if not previously present, makes its 
appearance, from which the disease receives its name. The 
vomiting becomes copious, and hemorrhages occur. They 
may be from the nose, lungs, bowels, or, more commonly, 
from the stomach (the characteristic black vomit). The black 
vomit consists of altered blood, with parts of the gastric con- 
tents. Nervous symptoms now appear ; the mind, which has 
remained clear up to this time, becomes clouded, and the 
patient dies in coma.- Recovery may even follow some of the 
severe symptoms just enumerated, but this is most unusual. 
The duration of this stage is indefinite, lasting a week or more. 

Types. — Mild, severe, or grave (hemorrhagic) cases occur 
during an epidemic. 

Diagnosis. — This depends upon the knowledge of an epi- 
demic, the disproportion of pulse to temperature, the early 
albuminuria, the yellow discoloration of the skin, and the 
black vomit. The agglutination test may be useful. 

Differential Diagnosis. — This disease must be differentiated 
from dengue, in which the prominence of pain in" the joints 
and bones coming on suddenly, with high fever and rapid 
pulse, are seen ; absence of albuminuria ; grave gastric symp- 
toms, and hemorrhages. Jaundice is not present. 

Prognosis. — Mortality is high, in some epidemics reaching 
50 fo. Unfavorable symptoms are jaundice, hemorrhages, 
rapid pulse, and high fever. 

Prophylaxis. — Isolation of all cases and even of suspected 
cases, as the disease is both contagious and infectious. 

Treatment. — Disinfection of the person and effects. Strict 
quarantine. There is no known means of aborting the attack. 
Patient should be placed in bed, and have absolute rest, good 
ventilation, and hygienic surroundings. A mild cathartic 
should be given at the onset. Calomel is perhaps the best 
drug. Vomiting and gastric irritability may be treated by 
carbolic acid, cocain, or broken doses of calomel. Dry iced 
champagne is of use in some cases. The fever should be 



DENGUE. 1 95 

treated by cold applications to the head and cold sponging. 
For the pain opium in some form is the most useful drug. 
Strychnin is of use in cardiac asthenia. Acidulated drinks in 
small quantities are grateful to the patient. For the hemor- 
rhage opium, ergot, and suprarenal capsule extract may be 
used. 

DENGUE* 

Definition. — An acute, infectious, febrile disease of short 
duration, prevailing in epidemics in warm climates, character- 
ized by an active febrile movement, with remissions, intense 
headache, pain in the joints and muscles, cutaneous eruptions, 
and low mortality. 

Synonyms. — Breakbone fever ; dandy fever ; broken-wing 
fever. 

Etiology. — This disease is markedly contagious, occurring 
in widely spread epidemics in tropic and subtropic countries, 
at all ages, in both sexes, and attacks the majority of the 
population. The specific cause has not been definitely deter- 
mined. The disease appears particularly in seaport cities. 

Period of Incubation. — From two to five days. 

Symptoms. — The disease begins with marked chill and 
rigors, and the temperature rises abruptly. There is pro- 
nounced headache, particularly in the temporal regions ; in- 
tense pain in the back ; and characteristic pain in the joints 
and bones. This produces a marked stiffness and a corre- 
sponding gait ; hence the synonyms breakbone fever and dandy 
fever. Gastric symptoms are marked ; tongue is thickly 
coated ; there are complete loss of appetite and marked thirst. 
In this stage eruptions may occur : they are usually of a vaso- 
motor nature. The face is red, the eyelids are swollen, and 
the conjunctivae are injected. The prostration is extreme. 
This stage lasts about three days (" three-day fever"). Oc- 
casionally, the temperature may fall at the end of the first or 
second day, either by lysis or by crisis, and when by the latter, 
there is profuse sweating. This is followed by a period of 
apyrexia, and eruptions are likely to show themselves : ery- 
thema, urticaria, herpes, etc. The fever rises again to its former 
height or even higher, but terminates rapidly, lasting about 
two or three days. Irregular cases and cases in all degrees 
of severity appear during an epidemic. 

Diagnosis. — This depends upon the presence of an epi- 
demic, abruptness of the onset, early occurrence of the joint 



: 9 6 



INFECTIOUS DISEASES. 



and muscle pains without redness and very little swelling, 
remissions during the course of the attack, with eruptions, 
swelling of the glands, and profound prostration. 

Differential Diagnosis. — Differential diagnosis must be 
made between dengue, influenza, and yellow fever. 



Dengue. 

Where occurring ... In tropic and sub- 
tropic countries. 

Numbers affected . . . Large majority of 
population. 

Nature Contagious. 

Duration of epidemic . Two to five months. 

Affects whom All races. 

Period of incubation . Two to five days. 

Characteristics .... Severe pains in 
joints and mus- 
cles. 

Ambulatory cases . . . Frequent. 

Catarrhal symptoms . Extremely rare. 

Pneumonia or pleurisy Rare. 
Gastric symptoms . . Prominent. 

Diarrhea Rare. 

Spleen Not enlarged. 

Pulse and temperature Rapid and high 
fever. 

Eruptions Frequent. 

Hemorrhages Rare. 

Albuminuria None. 

Mortality Low. 

Sequels Rare. 



Rheumatic fever may resemble dengue, the acid sweats, car- 
diac complications, the less severe onset, the symmetric in- 
volvement of the joints, with redness and swelling, all point- 
ing to acute rheumatic fever. 

Prognosis. — The disease is rarely fatal. 

Treatment. — No specific treatment. A purge should be 
given at the onset and opium and its derivatives to relieve 
pain. Antipyretics may be of use. Administration of quinin 
is without avail. During convalescence the patient should 
have an abundant supply of nutritious food and tonics. 



Influenza. 


Yellow Fever. 


In all countries. 


In tropic and subtropic 




countries. 


Large majority of 


Cases limited. 


population. 




Contagious. 


Contagious. 


Six to eight weeks. 


Indefinite. 


All races. 


Foreigners particular- 
ly- 
One to seven days. 


From a few hours 


to a few days. 




General muscular 


General muscular 


pains. 


pains. 


Frequent. 


Rare. 


Characteristic. 


No catarrhal symp- 




toms. 


Frequent. 


Rare. 


Not so prominent. 


Nausea and vomiting 




characteristic. 


Frequent. 


Constipation. 


Enlarged. 


Slightly enlarged. 
Pulse slow and temper- 


Rapid and high 


fever. 


ature not so high. 


Rare. 


Jaundice. 


Rare. 


Common. 


None. 


Constant. 


Somewhat higher. 


Very high. 


Common, frequent. 


None. 



PERIODIC FEVERS. 
MALARIA. 

Definition. — Malaria is an infectious disease, characterized 
by periodicity of symptoms ; anatomically, by enlargement 
of the spleen, and in the blood by the presence of the specific 
parasite. 



Plate IV. 




Showing the distribution of malaria as indicated by the shading (modified from 
Mannaberg, "Die Malaria Krankheiten " ). 



Plate IV 



s & w 




MALARIA. I97 

Groups. — Tertian fever, quartan fever, and estivo-autumnal 
fever. The tertian and quartan fevers are usually intermittent, 
and the estivo-autumnal fever is remittent or continued. 

Synonyms. — Malaria literally means " bad air." Malaria; 
chills and fever ; ague ; intermittent fever ; remittent fever ; 
swamp fever ; chagras fever ; Panama fever ; Roman fever ; 
African fever ; black-water fever. 

History. — Meckel, in 1847, found in the blood of a cadaver 
dead of malarial fever oval and round pigmented bodies that 
were probably the specific parasite. In 1849 J- K. Mitchell, 
of Philadelphia, found pigment in the blood of a malarial 
patient. Lewis, an English observer, found hematozoa in the 
blood of rats. To Laveran, a French army surgeon, is due 
the credit of the discovery, in 1880, of the malarial parasite. 

Etiology. — Predisposing Causes. — Malarial fevers are 
prevalent in most parts of the world. They are, however, 
mostly a disease of tropic and subtropic countries, and appear 
much less frequently in temperate zones. 

Seasons. — In the tropics malarial fevers are endemic 
throughout the year. In subtropic and temperate climates 
they are most frequent in August, September, and Octo- 
ber, then decreasing in severity toward December and in- 
creasing again in the early months of the year, until they 
reach their maximum about September. In the early months 
of the year the infections are rather mild, the tertian and 
quartan types being usually single and most frequent ; the 
severer ones in the early fall, being usually double tertian, 
quartan, and estivo-autumnal. 

Influence of Soil, Moisture, and Altitude. — Lowlands, 
river-bottoms, and swamps favor infection. Decaying vege- 
table matter also seems to predispose. In mountainous 
regions malaria is of rare occurrence. Cultivation of the 
soil and drainage seem to lessen the liability of contracting the 
disease. It is supposed that winds play some part in its spread. 

Race, Occupation, Age, and Sex. — The white race is most 
susceptible ; negroes and Indians to a lesser degree. Occu- 
pations that expose individuals to moisture and contact with 
the soil, such as laborers upon public works, road-making, 
gardening, fruit-gathering, etc., predispose. Most frequent in 
early adult life, less so in the extremes of age. Women are 
less frequently attacked, being less exposed. (It has been 
demonstrated by Thayer that congenital malaria probably 
does not exist.) 



I98 INFECTIOUS DISEASES. 

Exciting Cause.— Plasmodium malariae, or hematozoon of 
Laveran. This parasite belongs to the group of protozoa. 
It has not been demonstrated in soil or water, and all attempts 
at cultivation have failed. It has, however, been found in the 
bodies of certain species of mosquitos. The mode of en- 
trance into the blood of man has not been clearly demon- 
strated, except perhaps by infection from mosquitos. It is 
supposed to gain entrance into the human economy through 
the respiratory tract, the digestive tract, and the skin by 
direct inoculation. 

Parasite. — There are three varieties of the parasite : ter- 
tian, quartan, and the parasite of estivo-autumnal fever. 

Description of Parasites. — Tertian. — Its life's cycle is forty- 
eight hours. When first seen in the red blood-cell in its 
youngest form, it is a small hyaline ameboid body. It con- 
tinues to grow at the expense of the erythrocyte, which 
rapidly loses its color, becoming quite pale. The parasite 
soon takes on fine pigment that is of a yellowish-brown 
color. The ameboid movement is quite active, and the pig- 
ment also appears to be in rapid motion. As it reaches 
maturity the erythrocyte increases in size, and when full 
grown, is larger than the normal red blood-cell. The pig- 
ment now gathers to the center and segmentation occurs, 
forming a roset body ; there are usually two rows of leaflets, 
each segment forming into a distinct spore, numbering from 
twelve to twenty. 

The shell of the corpuscle ruptures, and the spores are lib- 
erated about the time of the paroxysm. These again attempt 
to gain entrance to the healthy red blood -cells, the phagocytes, 
however, destroying the greater number. Flagellate bodies 
may be regarded as accidental forms developed from the full- 
grown parasite. 

Quartan. — The cycle of development in this variety is 
seventy-two hours. In the red blood-cell in its youngest 
form it is found as a small hyaline body. Its growth is less 
rapid than the variety just described, and takes on pigment 
that is quite coarse and of a dark-brown color. As the para- 
site grows the erythrocytes decrease in size and become brassy 
in color. Ameboid movement in the quartan type of parasite 
is sluggish, and the pigment is not in active motion ; when 
full grown, it is smaller than the red blood-cell. The pigment 
now gathers to the center as a star-shaped mass and segmen- 
tation occurs, forming one row of leaflets that develop in from 



Description for Plate V. 

A. Figs. I to 22. — Stages of development of the tertian parasite. (Fig. 17 
and Fig. 18, after Thayer and Hewetson). 

Figs. 23 to 29. — Hydropic degenerated malarial bodies, 

B. Schematic sporulation of the tertian parasite (after Golgi). (From Manna- 
berg, "Die Malaria Krankheiten." ) 



Plate V. 
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Description for Plate VI. 

A. Figs. I to 22. — Stages of development of the quartan parasite. 
Fig. 23. — Rare sporulation form (after Canalis). 

B. Schematic sporulation of the quartan parasite (after Golgi). 

C. Leukocytes containing melanin. 

D. Various vacuolation of the erythrocytes. (From Mannaberg, " Die Malaria 
Krankheiten. " ) 



A 1 



Plate VI. 



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Description for Plate VII. 

A. Figs. I to 6. — Pigmented quotidian parasites. 

B. Figs. 7 to 13. — Unpigmented quotidian parasites. 

C. Figs. 14 to 19. — Malignant tertian parasites. 

D. Fig. 20. — Brass-colored erythrocyte. 
Figs. 21 to 37. — Crescentic bodies. 

Figs. 24 to 26. — Fusion of two ameboid parasites (copulation). 

Fig. 27. — Conjunction of two bodies. 

Figs. 38 to 40. — Stained crescents (by Romanowsky's method). 

Figs. 41 to 58. — Stained parasites of the second group. 

Figs. 49 to 57. — Formation of the crescents (conjunction of the bodies) (stained 
with hematoxylin after fixation by picric acid). (From Mannaberg, " Die Malaria 
Krankheiten." ) 

Note. — Mannaberg recognizes three varieties (namely, the pigmented quoti- 
dian, the npigmented quotidian, and the malignant tertian) of that class of 
parasites which is characterized by almost exclusive sporulation in the internal 
organs and the formation of crescentic bodies, described on page 199 as the 
estivo-autumnal parasite, without special subdivision. 



Plate VII. 



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MALARIA. I99 

six to twelve spores. About the time of liberation of these 
spores the paroxysm occurs. Flagellate bodies may also be 
found. 

Estivo-autumnal. — The youngest form of this parasite is 
found in the red blood-cell as a hyaline ameboid body, being 
usually ring-shaped and appearing toward the periphery of the 
corpuscle. The life cycle of this parasite varies from twenty- 
four to forty-eight hours, and occasionally longer. The hya- 
line bodies are found in the peripheral circulation ; further 
maturity of the organism takes place in the internal organs — 
spleen, liver, bone-marrow, etc. By splenic puncture various 
stages of the development may easily be found. After the 
infection has persisted for from five to seven days, crescent- 
shaped bodies and oval and round forms are found in the 
peripheral circulation as well as the hyaline bodies. 

Flagellate bodies may also be found. (For method of ex- 
amination of the blood-cells see p. 150.) 

Period of Incubation. — Tertian parasite, ten days ; quartan 
parasite, thirteen days ; estivo-autumnal parasite, three days. 
(This represents the time required for a sufficient multiplica- 
tion of the parasite to produce symptoms.) 

The effects upon the system are probably produced by three 
conditions : first, changes resulting from disintegration of the 
erythrocyte and liberation of spores ; second, accumulation of 
pigment from this disintegration ; and third, the influence of 
toxic materials produced by the parasite. 

Pathology. — The spleen is always enlarged and dark in 
color. In all cases of chronic malaria the spleen may show 
marked pigmentation of a slate color, and becomes greatly 
increased in size. Sometimes perisplenitis exists. Rarely, 
cirrhosis of the liver follows, but this organ reveals pigmenta- 
tion. The kidneys are enlarged and of a reddish-gray color, 
and may show parenchymatous change. Considerable pig- 
ment is found. Bone-marrow is usually of a deep-red color, 
and may also show melanotic pigmentation. Amyloid disease 
may result from malaria. Anemia rapidly develops, as a result 
of malarial infection. The erythrocytes are reduced, in severe 
cases the number reaching 500,000 in a cubic millimeter. The 
hemoglobin shows a greaterreduction than the corpuscles. Free 
pigment may be found in the plasma and also in the colorless 
corpuscles. The leukocytes are not increased. Malarial 
bodies are commonly found in the phagocytes. The long- 
continued attacks of malaria may give rise to malarial cachexia, 



200 



INFECTIOUS DISEASES. 



being severe anemia with jaundice. The complexion in this 
condition is muddy and of a grayish-yellow tint. 

Symptomatology. — Tertian. — Prodromes are rare, and are 
characterized by periodicity, consisting of vague pains, slight 
nausea, and chilliness. The paroxysm consists of three 
stages : chill, fever, and sweating. 

First Stage. — A few hours before the chill headache and 
a sense of uneasiness may be experienced. The onset is 
abrupt, with chilliness resulting in a distinct rigor ; this lasts 
from fifteen to forty minutes or more. The symptoms accom- 




Fig. 28. — Temperature-curve in a case of tertian fever. 



panying this stage are creepy sensations over the body, espe- 
cially down the spine, yawning, and a certain amount of cya- 
nosis. These symptoms are evidences of the contraction of 
the peripheral blood-vessels, causing absence of blood in the 
periphery of the body, with an increase in the visceral blood. 
Occasionally, there is nausea ; sometimes there are vomiting, 
chattering of the teeth, and a rapid pulse, which is small and 
hard. The temperature, as registered by a surface thermome- 
ter, is subnormal, but the rectal and axillary temperature is 
high. 



MALARIA. 201 

Second Stage. — The cold stage merges into the hot stage, 
which lasts from one' to four hours. There are now sensa- 
tions of heat, flushed face, injected eyes, full, bounding pulse, 
thirst, intense headache, restlessness, and even delirium. The 
temperature rises to 103 F. or higher. 

Third Stage. — The hot stage is soon followed by the third 
stage — that of sweating ; this begins with sweating of the 
face, rapidly spreading over the entire body, terminating in a 
very profuse sweat, lasting from one to three hours. The 
temperature begins to fall, and at the end of this stage reaches 
the normal or subnormal. Headache persists for some time 
afterward, as a rule being frontal in character. Herpes is 
frequently seen, and albuminuria may be present. 

Intermission. — This is followed by a period of intermission 
lasting from thirty-six to forty-eight hours, during which time 
the temperature is normal or subnormal. The patient feels 
perfectly well, and is able to be about. This period continues 
until the next paroxysm, when the train of symptoms is again 
repeated. The regularity of these stages depends upon the 
uniform growth of the parasite, so that they sporulate almost 
simultaneously. 

Occasionally, an individual is infected upon two successive 
days. In such an event there are two distinct groups of 
parasites that sporulate on consecutive days, causing a daily 
paroxysm (quotidian fever). In long-continued infections the 
growth of the parasite may become somewhat irregular, so 
that segmentation does not take place at a given time. As a 
result of this the chill may be prolonged or even absent. 
The fever may be somewhat irregular or, in rare cases, con- 
tinued or absent. The sweating stage may show variation. 
In order to ascertain the variety of the type a blood exami- 
nation is necessary. 

Quartan Type. — This is the rarest of the malarial infec- 
tions. It is found in parts of Italy, especially the Pontine 
marshes. The clinical manifestations of the paroxysms are 
similar to those just described in the tertian variety. The 
paroxysm occurs every seventy-two hours in the single infec- 
tion. A double infection may occur, giving rise to a par- 
oxysm on two successive days ; then a day intervenes, and 
again two successive paroxysms follow, etc. The quotidian 
type of fever may also occur as the result of a triple infection. 



202 



INFECTIOUS DISEASES. 



ESTIVO-AUTUMNAL TYPE. 

(Sometimes Called Continued, Remittent, or Irregular.) 

Varieties. — First, quotidian intermittent fever ; second, 
tertian estivo-autumnal fever ; third, pernicious estivo-autum- 
nal malaria. 

Estivo-autumnal fever is commonly found in the tropics, and 
rarely in temperate climates. 

Quotidian Intermittent. — This is characterized by daily 
paroxysms, as described in the tertian variety. The regularity, 
however, has a tendency to vary. 

Tertian Type. — This is characterized by paroxysms every 



June | agT 



3 4 5 



30 



Hour 



S S z s s 



Hour 



Temp. 

105 
104 
103 
102 
101 
100 



JE 



^ 



83s 



II 



?3 



£ 



&; 



£* 



Temp, 

c. 



40 



£ 



37 



Fig. 29. — Temperature-curve in a case of estivo-autumnal fever. 



forty-eight hours that may resemble the tertian type, and show 
a tendency to become irregular. 

Pernicious Malaria. — This type is commonly associated 
with the estivo-autumnal parasite — rarely with the tertian. It 
is produced either as a result of the severe infection, usually, 
of the estivo-autumnal parasite or of great abundance of 
parasites. 

Different Groups. — Three distinct and well-defined groups 
have been differentiated : the algid, the comatose, and the 
hemorrhagic form. 

Algid Form. — The algid form is characterized by marked 
gastro-intestinal symptoms, vomiting, abdominal cramp, with 



ESTIVO-AUTUMNAL TYPE. 203 

frequent stools. The urine is diminished, the pulse is feeble, 
and the temperature may be normal or subnormal. 

Comatose Form. — The comatose form closely resembles an 
apoplectic stroke. The subject is suddenly stricken with un- 
consciousness or with acute delirium, with rapidly oncoming 
coma and chill. The unconsciousness continues, and the 
patient dies in coma. The temperature may be elevated at 
first, but in a day or two it falls to normal or subnormal. 

Hemorrhagic Form. — The hemorrhagic type may occur in 
all the forms of severe malarial infections. Hemorrhage occurs 
most frequently from the kidneys, being either a hemoglobin- 
uria or a hematuria. Suppression of the urine is occasionally 
met with, the patient dying from this cause. It is often called 
" bilious hemorrhagic fever." 

Malarial Cachexia. — It is the result of long-standing in- 
fection or repeated infections, causing severe anemia and char- 
acteristic discoloration of the skin, being of a muddy grayish 
color. The enlargement of the spleen is marked. 

Combination of Type. — Some of the varieties just de- 
scribed may be combined. 

Complications and Sequels. — Pneumonia, dysentery, ne- 
phritis, and enteric fever are sometimes concurrent affections. 
To the latter cases the term typhomalarial fever has been in- 
correctly applied. There is no mixture of type, the enteric 
fever running its course, the malaria being an intercurrent 
affection, or vice versa. Other complications, such as tuber- 
culosis, orchitis, or adenitis, may occur. 

Relapses. — Relapses are frequent, occurring after a period 
of weeks or months, sometimes of a year or more. 

Diagnosis. — Diagnosis depends upon the finding of the 
parasites in the blood, and it may be said with accuracy that 
the type of fever may be determined, and with some certainty 
the time of the paroxysms. No diagnosis of malarial fever 
should be made in any fever showing irregular or regular type 
without the presence of the plasmodium. The therapeutic test 
should not be employed as a method of diagnosis. 

Prognosis. — In temperate climates the prognosis is good, 
the mortality being very low. In tropic and subtropic coun- 
tries in which the severer infections by the estivo-autumnal 
parasites occur, the prognosis is unfavorable unless quinin can 
be administered early and in sufficient quantities. 

Prophylaxis. — Thorough drainage and systematic cultiva- 
tion decreases its prevalence. If one enter into a malarious 



204 INFECTIOUS DISEASES. 

district, high ground should be selected for living purposes 
and the night air avoided. Mosquito-netting is of use. Quinin 
may be administered in small doses as a prophylactic. 

Routine Treatment. — Rest in bed, if possible, is desirable, 
especially in the severer infections. Quinin is the specific, 
and should be administered in doses sufficient to produce its 
physiologic effect. In the ordinary tertian form fifteen to 
twenty grains a day, preferably given in solution, will be 
usually found sufficient. In the severer forms and in per- 
nicious malarial fever it is always best to give quinin hypo- 
dermically. The treatment may be begun by the preliminary 
administration of a laxative dose of calomel, but the 
specific (quinin) should be employed as soon as possible. 
Arsenic and methylene-blue may be used. A spontaneous 
recovery rarely takes place. 

Treatment in any case should be continued for a period of 
some weeks after all symptoms have disappeared, as relapses 
are common. 

Treatment of Malarial Cachexia. — Change of climate, a 
long sea voyage, and arsenic constitute the most favorable 
treatment of this condition. Quinin is of very little service. 
Warburg's tincture is often useful. 



THE EXANTHEMATA OR ERUPTIVE FEVERS. 

This group comprises scarlet fever, measles, German 
measles, variola, vaccinia, varicella, and, for the sake of con- 
venience, erysipelas may be included. These fevers have 
certain well-marked characteristics. They are diseases of 
childhood, and are eminently contagious, having a known and 
well-defined period of incubation. They are all self-limited. 
Each is characterized by a well-defined eruption, appearing 
upon a certain day and in a definite manner. They have 
special sequels. There is no specific treatment, except in the 
case of vaccination, which is preventive in the variolous dis- 
eases. 

SCARLET FEVER. 

Definition. — An acute, specific, contagious disease, char- 
acterized by a scarlet eruption that occurs early on the second 
day, with sore throat, high fever, and frequent implication of 
the kidney. 



SCARLET FEVER. 2C»5 

Synonym. — Scarlatina. 

This disease was first clearly described and differentiated 
from measles by Sydenham some time between the years 1661 
and 1665. It first made its appearance in America in 1735. 
It prevails in all parts of the world, but is more common in 
cold and temperate climates. When it occurs in the tropics, 
it is comparatively mild. 

Etiology. — Predisposing Causes. — Age is an important 
predisposing cause : it rarely occurs after the tenth year of 
life, although no age may be said to be exempt. Neither sex 
nor occupation predisposes. The form of so-called scarlet 
fever taking place after surgical operations, or coming under 
the hands of the obstetrician, may be due directly to infection. 
Surgical scarlatina has become a comparatively rare disease. 

Climate is of some importance, the disease existing princi- 
pally in cold and temperate regions. Epidemics are more 
prevalent in the winter. Sporadic cases "may appear at any 
time. There is a marked personal predisposition, some mem- 
bers of a family being more liable to the disease than others. 
A certain proportion of the population is particularly immune, 
even failing to contract the disease when directly exposed. 

Exciting Cause. — Undoubtedly a specific, infectious prin- 
ciple ; it is always derived from a previous case. The excit- 
ing cause has not yet been demonstrated ; the infection is 
readily carried by fomites. The vitality of the infectious 
principle may be measured by months or by a year or more ; 
it is extremely tenacious. The poison leaves the body largely 
by the scales that are shed during the period of desquama- 
tion, and probably by exhalation. The poison may also leave 
the body by the urine and by pus from abscesses. The dis- 
ease is contagious throughout its entire course, — probably 
more so during the time that the rash makes its appearance, — 
and persists until desquamation has been entirely completed, 
or even longer in cases attended by discharges from ulcerated 
surfaces or abscesses. The infective principle probably enters 
the body by the respiratory mucous membrane and the diges- 
tive tract. One attack confers immunity, as a rule. 

Pathology. — The toxic agent produces inflammation of 
the tonsils and adjacent parts, causing fever and a diffuse 
rash. There are no characteristic changes produced in the 
organs or the tissues. Morbid conditions occurring in the 
intense febrile processes are found in this disease. Enlarge- 
ment of the lymph-glands in various parts of the body, and 



206 INFECTIOUS DISEASES. 

complications, such as endocarditis, pericarditis, and inflam- 
matory changes in the kidney (postscarlatinal nephritis) are 
common. 

Period of Incubation. — The period of incubation is from 
four to seven days. 

Symptoms. — The disease appears abruptly, with a chill, high 
fever, and headache. In children convulsions and vomiting are 
common. Vomiting is, perhaps, a more characteristic symp- 
tom in this fever than in any other of the acute infectious dis- 
eases occurring in children. Sore throat is an early manifes- 
tation, consisting of an intense hyperemia of the pharynx, the 
half-arches, and the tonsils. The fever is high from the 
onset, — 103 F. to 105 ° F., — and even rises with the appear- 
ance of the eruption, which may be at the end of the first or 
the beginning of the second day ; it remains high for four or 
five days, then falls in uncomplicated cases by rapid lysis. 

Eruption. — The eruption consists of pinhead points of a 
deep-red color, appearing first upon the neck and chest and 
spreading rapidly all over the body except certain parts of the 
face, the mouth, and chin. These red points, which are close 
together, soon coalesce, giving a diffuse pinkish or reddish 
appearance to the entire skin, which presents a boiled-lobster 
color. With this intense inflammatory process, which is a 
true dermatitis, some slight edema may be noted. Through- 
out the entire eruption raised papules are found. Itching 
during this time is a prominent symptom. The eruption lasts 
about four or five days. 

Throat Symptoms. — During the time that the eruption 
appears and throughout its course sore throat is a prominent 
symptom, even in the mildest cases. In severe cases diph- 
theric exudates are extremely likely to occur. 

The tongue in this disease is characteristic : a white fur 
soon makes its appearance, which in a day or two peels off, 
leaving raised papillae that give the tongue the appearance of 
a raspberry or strawberry ; this is sometimes called the " cat 
tongue." 

Nervous Symptoms. — Nervous symptoms are prominent : 
headache, delirium, and coma, and in children convulsions 
may mark the onset. 

Special Symptoms — The pulse-rate is increased in frequency 
— in mild cases from 120 to 140, and higher in the severer 
cases. Hemic murmurs are heard at the base of the heart. 
Slight enlargement of the spleen may be noticed. The urine 



SCARLET FEVER. 2C>7 

presents the usual characteristics of febrile urine, being scanty, 
high colored, and of high specific gravity, with albuminuria 
(toxic). The lymph-glands of the neck become prominent 
and swollen. 

Defervescence. — Defervescence occurs in from two to four 
days after the exanthem has been prominent. The fever and 
sore throat decline as the eruption begins to fade. 

Desquamation.- — The eruption first begins to disappear 
at the point at which it made its earliest appearance. The 
skin peels off, usually in large scales, occasionally in fine ones. 
Entire casts of the hand or foot may come away during this 
stage. The duration of the period of desquamation is a 
variable one, and it may last from three or four days to a 
month or more. 

During the period of desquamation polyarthritis and 
inflammation of the tendons may appear. The joint in- 
flammation is generally of a fleeting character, and does 
not persist, excepting in those cases in which pus forms and 
the joint becomes septic. A common occurrence during 
this period is acute nephritis, known as postscarlatinal nepli- 
ritis. 

Nephritis. — The symptoms of this important condition are 
ushered in by a rise in temperature. The face becomes ede- 
matous, edema also showing itself in the feet, with extreme 
pallor of the face. The urine is scanty, and anuria may even 
occur ; it may also contain blood. Chemic and microscopic 
examination of the urine shows all the characteristics of an 
acute nephritis. 

Eye Symptoms. — Keratitis and iritis are met with. 

Ear Symptoms. — Otitis media is very common in this 
affection, appearing more frequently than in any of the other 
acute infectious diseases. 

Gastrointestinal Tract. — The stomach and intestines 
may show symptoms of inflammation, or hemorrhages may 
occur. At the onset of the disease diarrhea frequently 
appears, soon, however, giving place to constipation. 

Respiratory Symptoms. — Symptoms relating to the respi- 
ratory system are rare in scarlatina. 

From the general infective process, especially in the severer 
forms, septicemia and pyemia occur. 

Complications. — Diphtheria is the most important compli- 
cation, and occurs in nearly all severe cases. Endocarditis 
appears ; less commonly, pericarditis. Meningitis and peri- 



208 INFECTIOUS DISEASES. 

tonitis complicate this disease. Pleurisy with and without 
effusion is not rare. 

Sequels. — Enlarged lymphatic glands, chronic joint affec- 
tions (with and without pus), hemorrhagic diathesis, mono- 
plegia, hemiplegia, peripheral neuritis, hysteria, and anemia 
are the common sequels. 

Varieties. — Four well-defined varieties of this disease are 
recognized: (i) Scarlatina simplex, or simple scarlatina; (2) 
scarlatina anginosa, or the variety in which the throat 
symptoms are most prominent ; (3) scarlatina maligna 
(hemorrhagic scarlet fever) ; (4) latent, larval, or undeveloped 
scarlatina. 

Scarlatina Simplex. — The symptoms are those already 
described, in which few, if any, complications occur, the active 
symptoms being over in a week or less. 

Scarlatina Anginosa. — Scarlatina anginosa is characterized 
by prominence of throat symptoms, diphtheria being an 
almost constant complication. Great enlargement of the 
lymphatic glands of the neck shows itself in this form. The 
appearance is characteristic, and has been called the " collar 
of brawn." 

Scarlatina Maligna. — Scarlatina maligna shows all the 
symptoms of an intense infection. The eruption may appear 
as petechias ; the fever is high, hyperpyrexia being common ; 
and the disease may end fatally in two or three days, with all 
the symptoms of an intense toxemia. 

Scarlatina Latens. — In this form the symptoms are mild ; 
fever may be moderate, the eruption appearing scantily or 
not at all, and may only be recognized by complications or 
sequels, particularly postscarlatinal nephritis. 

Diagnosis. — This depends upon the knowledge of an epi- 
demic ; the sudden onset, with chill or convulsions, vomiting, 
high temperature, headache, sore throat, an exceedingly rapid 
pulse, — 140 or more, — and the appearance of the eruption 
late in the first or early in the second day. 

Differential Diagnosis. — This must be made between scar- 
let fever, measles, German measles, and simple erythema. 
In simple erythema fever is usually absent, sore throat is not 
prominent, the eruption shows itself in different parts of the 
body and not as a general diffused rash, and there is an absence 
of desquamation. In doubtful cases some time must elapse 
before the diagnosis can be definitely made. 



SCARLET FEVER. 



209 



Scarlet Fever. 

Period of incubation Four to seven days. 

Rash Dusky red and dif- 
fuse ; great itching 
of the skin appear- 
ing from first to 
second daw 



Catarrhal symptoms Throat affect ion 
prominent ; con- 
junctivas unaf- 
fected ; lung com- 
plications rare; di- 
arrhea prominent 
earlv. 



Lymphatic glands . Prominent about the 
neck, proportionate 
to throat implica- 
tion. 



General symptoms 



Albuminuria . 
Convalescence, 

Desquamation 



. Characteristic (straw- 
berry) tongue ; high 
temperature ; rapid 
pulse ; vomiting ; 
marked nervous 
symptoms. 

. Frequent. 

. Prolonged, owing to 

complications. 
.Copious, in large 

shreds. 



^Measles. 

About ten days. 

Papular, brick-red, 
darker, crescentic 
in shape, occurring 
about the mouth 
and forehead, with 
intervening healthy 
skin ; eruption on 
fourth day. 

Little or no sore 
throat; catarrh; 
conjunctivitis; lac- 
rimation and pho- 
tophobia ; bronchi- 
tis marked ; bron- 
chopneumonia com- 
mon ; diarrhea fre- 
quent. 

Not marked early ; 
limited to the angle 
of the jaw. 



Little depression; 
tongue furred ; ano- 
rexia ; temperature 
not so high ; pulse 
in proportion to the 
fever ; marked ca- 
tarrhal symptoms. 

Rare. 

May be prolonged. 



Rubella. 

About eighteen days. 

Rose-red spots, irreg- 
ular in outline, ap- 
pearing upon the 
first dav. 



Slight sore throat ; 
conjunctivitis; 
bronchitis slight ; 
no diarrhea. 



Generally enlarged 
and tender, the pos- 
terior chain being 
particularly impli- 
cated. 

Little or no depres- 
sion ; appetite often 
retained ; tempera- 
ture slightly above 
normal; little 
change in pulse ; 
symptoms slight. 

Absent. 

Rapid. 



Seldom copious ; fine May be copious ; al- 
scales. ways in fine shreds. 



Prognosis. — In very young children — under five years — 
the prognosis is extremely grave. In older ones in whom the 
severer complications are absent recovery usually takes place. 
Diphtheria is one of the most serious complications, and ren- 
ders the prognosis grave. Early severe nervous symptoms, 
high fever, persistent vomiting, and rapid pulse are unfavorable. 

Treatment. — Strict isolation is important. A room should 
be selected, if possible, at the top of the house. All unneces- 
sary articles of wearing apparel, bed-linen, etc., that have 
come into contact with the patient should be destroyed by 
fire. The room should have a temperature of about 70 ° R, 
with good ventilation. An open fireplace is extremely useful 
for this purpose. The scales during the period of desqua- 
mation should be carefully collected and burned. 

Diet. — The diet should be of an easily assimilated, nutritious 
character. Fluids, such as pure drinking-water or the alkaline 
mineral waters, should be freely administered. Milk is a nec- 
essary article of diet. 

There is no specific treatment. A mild laxative should be 
given at the onset. This should not, however, be continued 
throughout the course of the disease, on account of the in- 
flammation that may be present in the bowels. Tepid spong- 
14 



2IO INFECTIOUS DISEASES. 

ing at least twice daily is necessary in severe cases. The cold 
bath is not advisable ; warm bathing is, however, usually very 
grateful to the patient. 

During the period of eruption an animal fat used as an in- 
. unction to the skin prevents itching and hastens desquamation. 
The administration of chloral hydrate, as first recommended 
by J. C. Wilson, is of great use in the majority of cases. 
Sufficient should be given to the child to keep it in a mildly 
somnolent condition. It also acts as a diuretic, and in this 
way may prevent nephritis, which so frequently follows this 
disease. 

It is necessary to make daily examinations of the urine 
during the period of desquamation so that nephritis may be 
detected as soon as possible. 

Complications must be treated upon general principles. 

MEASLES. 

Definition. — An acute, infectious, contagious disease, char- 
acterized by marked catarrhal symptoms, especially of the res- 
piratory tract, with a characteristic eruption occurring upon 
the fourth day. 

Synonyms. — Morbilli ; rubeola. 

Etiology. — Particularly a disease of childhood. Sex not a 
predisposing cause. Occurring in temperate and cold climates, 
usually in the winter months. 

Exciting Cause. — This is unknown, but is very probably a 
specific infecting principle that is carried by fomites and that 
is very diffusible. 

Period of Incubation. — The period of incubation is about 
ten days. One attack usually confers immunity, but a second, 
a third, or even a fourth attack has been noted. 

Pathology. — There is no characteristic lesion. The in- 
flammatory areas in the skin show infiltration of leukocytes, 
especially into the vessels, the sebaceous glands, and the sweat- 
glands. Bronchopneumonia is commonly the cause of death 
in measles. 

Symptoms. — The disease may begin with a chill, followed 
by fever that may reach 103 R, or higher, upon the first 
day, with catarrhal symptoms from the onset. Injected con- 
junctiva, lacrimation, photophobia, coryza, and some cough 
are early manifestations. Rales are heard in the chest. At 
this time bluish points, surrounded by a white area known as 



MEASLES. 211 

Koplik 's sign, may be noticed upon the buccal mucous mem- 
brane. 

On the second day the temperature falls rapidly, and re- 
mains subfebrile for about two days. On or about the fourth 
day the characteristic eruption appears, with a rise in the tem- 
perature. The fever again reaches 103 ° F. to 104 F. The 
eruption appears first upon the face and neck, spreads rapidly 
over the entire body, from twelve to thirty-six hours usually 
elapsing before the whole body is covered. The eruption 
consists of a rose-red or brownish maculopapular eruption 
raised above the skin, with intervening healthy skin, often ar- 
ranged in a crescentic shape, especially upon the forehead and 
wrists. The eruption remains at its height for about four 
days. The catarrhal symptoms meanwhile continue, and even 
slight exacerbations take place. At the end of this period — 
about the eighth day from the beginning of the disease — the 
eruption fades, first from the face, neck, and chest, and then 
from the rest of the body. A fine desquamation occurs at the 
end of this period. The temperature about the seventh or 
eighth day falls abruptly to normal or slightly below, and in 
the absence of complications remains normal. 

Gastrointestinal Symptoms. — The tongue is coated, but 
not characteristic. Anorexia is complete. Diarrhea may be 
present from the onset of the attack, for it is probable that 
the same catarrhal process takes place in the digestive tract. 
The catarrhal symptoms gradually decline, and about the 
twelfth day of the disease in uncomplicated cases convales- 
cence is reached. This is usually rapid, the child speedily 
regaining its normal condition. 

Complications. — Bronchopneumonia is the most important 
and serious complication of this disease. Pleurisy occurs in 
a fair proportion of cases. Endocarditis and pericarditis are 
rare, and inflammation of the kidneys is extremely infrequent. 
Hemorrhagic measles also occurs. 

Sequels. — Otitis media, chronic bronchitis, and tubercu- 
losis are the most frequent sequels. 

Diagnosis. — Depends upon the sudden onset, marked 
catarrhal symptoms, appearance of the rash upon the fourth 
day, typical fever-curve, and the prevalence of an epidemic. 

Differential Diagnosis. — German measles, or rubella, may 
be readily differentiated by an absence of marked catarrhal 
symptoms, by the fact that the rash occurs upon the first 
day, and by the milder course of the affection. 



212 INFECTIOUS DISEASES. 

Treatment. — Prophylaxis. — Prophylaxis presents great 
difficulties, owing to the great diffusion and infectiousness of 
the disease, and to the fact that the diagnosis can not usually 
be made before the characteristic eruption appears. If there 
are several children in the family, it is just as well if they all 
contract the disease, as in adults it is a very much more 
serious affection and complications are more likely to occur. 

There is no specific treatment, and in uncomplicated cases 
medicines are unnecessary ; a mild laxative at the onset is 
useful. The entire treatment should be directed to the pre- 
vention of complications, especially of bronchopneumonia. 
When complications occur, they must be treated upon general 
principles. 

RUBELLA. 

Definition. — An acute, infectious, contagious disease, 
occurring in epidemics, characterized by enlargement of the 
superficial lymphatic glands of the neck, slight fever, and mild 
catarrhal symptoms. 

Synonyms. — Rotheln ; French measles ; German measles ; 
epidemic roseola. 

Etiology. — This disease was described as a substantive 
affection early in the eighteenth century, and even up to the 
present time it has been regarded by some clinicians as related 
to measles and scarlet fever. It is, however, an independent 
affection, characterized by its own symptomatology and clini- 
cal course. It is a disease of childhood, occurring mostly 
before the fifth year and more particularly in temperate 
climates. 

Exciting Cause. — The exciting cause is unknown. It is 
highly contagious, and readily transmitted from the sick to 
the well. One attack confers immunity from itself, but not 
from measles or scarlet fever. 

Period of Incubation. — The period of incubation is from 
one to three weeks, usually estimated at eighteen days. 

Symptoms. — The onset is sudden, and probably the first 
symptom noticed is the eruption, which occurs irregularly 
over the face, neck, chest, body, and limbs, varying in indi- 
vidual cases and different epidemics. This multiform eruption 
may resemble erythema, urticaria, and, in some cases, that of 
true measles or scarlet fever. It is never, however, arranged 
in the form of crescents. It may be confluent or diffuse, last- 



VARIOLA. 2 I 3 

ing from two to four days. Desquamation occurs in fine 
scales. The fever is irregular, and may be absent altogether. 
Slight sore throat occurs, but this condition is usually trifling. 
There is enlargement of the superficial lymphatics, especially 
the cervical and postcervical chains. Suppuration is rare. 
The tongue is furred, the appetite is lost, and the urine pre- 
sents the* characteristics of febrile urine. Albuminuria is 
extremely infrequent. 

Complications. — Complications are uncommon, and are 
mostly found in cachectic or strumous children in foundling 
asylums or other large institutions for the young. Bronchitis 
and pneumonia are the most common. 

Prognosis. — The mortality is extremely low, less than 4^ 
of the cases proving fatal. 

Treatment. — Expectant and symptomatic. 

VARIOLA (SMALLPOX) . 

Definition. — An acute, infectious fever, markedly con- 
tagious, characterized by a typical eruption that passes 
through successive stages, and by high temperature and 
septic phenomena. 

Etiology. — Smallpox has been known from the earliest 
ages, even mummies having been found presenting the 
characteristic scars. It was introduced into Europe by the 
Crusaders, and was the great scourge of that continent for 
centuries, until the immortal discovery by Jenner of vaccina- 
tion. Neither sex nor age confers immunity. The fetus in 
utero may develop smallpox if the mother is affected. The 
liability to this disease is universal, except as controlled by 
vaccination. 

Negroes are especially prone to this disease. Climate and 
season are without influence, but epidemics more commonly 
occur in winter. 

Exciting Cause. — This is as yet unknown. The poison is 
rapidly communicable, both through the atmosphere and by 
fomites, and may retain its vitality for months and years. 
The disease is contagious from its onset. One attack usually 
confers immunity, but second attacks have occurred in isolated 
instances. It may be contracted from the cadaver of one 
having died from smallpox. 

Pathology. — The pathology consists principally in the 
cutaneous lesion, the pock appearing first as a distinct macule 



214 INFECTIOUS DISEASES. 

as a result of inflammation of the papillary layer of the 
skin, which causes the development of a hard papule. Lique- 
faction necrosis taking place, a clear serum exudates, and thus 
we have the conversion of the papule into a vesicle, and 
finally pus-corpuscles appear in the fluid, giving rise to the 
pustule. The umbilication is due either to a hair follicle in 
the center of the inflammatory zone, or to absorption being 
more rapid toward the center, thus causing the depression. 

In the hemorrhagic variety a bloody exudation is found in 
the vesicle, and the inflammatory area is also deeper. If sup- 
puration be marked, healing by granulation and cicatrization 
follows, and the deformity develops as a result of the con- 
tracting scar. Parenchymatous degeneration is found in the 
heart, liver, and kidneys. In severe cases fatty degeneration 
of the liver may be present. Hemorrhages may occur from 
the serous surfaces and also into the tissues. The leukocytes 
show a marked increase during the period of suppuration, 
which is especially marked in the hemorrhagic variety. 

In fatal cases the blood is dark, coagulation being imper- 
fect, as is found in other infections. Intense congestion of 
the internal organs with ulceration of the mucous membranes 
is found. The internal organs show the changes due to com- 
plications. The gastro-intestinal mucous membranes mani- 
fest the presence of the lesion in severe cases. The cuta- 
neous lesions shrivel after, death. Inflammations of parts of 
the brain and spinal' cord are noted. In the hemorrhagic 
variety large extravasations of blood are found in the skin and 
in the mucous membranes. In malignant cases death usually 
occurs before the eruption makes its appearance. 

Period of Incubation. — From ten to thirteen days. 

Symptoms. — The stage of invasion is sudden, with a pro- 
found, protracted chill. Milder cases may develop only a 
slight chilliness, but even this may be prolonged for some 
hours. The temperature rises abruptly from 102 F. to 105 
F. ; the pulse is increased in rapidity from 120 to 130. Gen- 
eral muscular pains are prominent, especially in the back, 
.which are continuous and very severe. Headache is an early 
symptom. In children convulsions may occur, being followed 
by delirium and coma. These symptoms continue until about 
the third day, accompanied by nervous symptoms, such as 
restlessness and stupor ; vomiting may also be present. 

On or about the third day there is a sudden remission in 
the temperature, the pulse-rate falling, and the severe symp- 



VARIOLA. 



215 



toms just enumerated suddenly disappearing, so that the 
patient imagines he is well. It will now be noticed that an 
eruption has appeared upon the face, thence spreading over 
the entire body. At first the rash is about the size of a pin- 
head, and soon becomes hard, feeling like a shot under the 
skin. The eruption may be discrete or confluent. This mac- 
ular eruption is rapidly converted into a papule of a reddish 
color. There may be itching and burning attending these 
early eruptive symptoms. 

In from twenty-four to forty-eight hours the rash has in- 
vaded the entire body. Great numbers of the individual 



Temp 



Day of Disease 



5 6 



9 10 • 11 12 13 14 15 16 17 18 19 



Temp 

c. 



106 
105 
10.4 
103 
102 
101 
100 
99 
98 



i 




m 



m 



s 



m 



»g 



41 



40 



39 



38 



37 



Stage of 
invasion. 



Stage Stage of Stage of Stage of 

of pap- vesicles. pustules. crusts, 

ules. 



Stage of 
desiccation. 



Fig. 30. — Temperature-curve of smallpox (after Eichhorst). 



papules have appeared, these being irregular in size. The 
earlier ones soon become vesicular, this change taking place 
about the sixth or seventh day from the onset of the attack. 
In a day or so the fluid becomes turbid and purulent, the top 
being held down {primary umbilicatioii) ; in from twenty-four 
to forty-eight hours this umbilication has disappeared, the 
pock now being conic in shape. About this time an intense 
red inflammatory areola is noticed about the base of the pock, 
and the eruption is now exceedingly painful. On or about 
the ninth day from the beginning of the disease suppuration 
begins in the pock, lasting about three days, when the apex 
of the cone drops in, due to the absorption of the contents of 



2l6 INFECTIOUS DISEASES. 

the pock (secondary umbili cation). When absorption has been 
completed, a crust forms that may remain for some days, these 
crusts falling off on or about the sixteenth day from the be- 
ginning of the disease, leaving depressed striated scars. 

During the time of suppuration the temperature rises again, 
and may be higher than during the initial stage. New symp- 
toms develop, which are septic in nature, such as convulsions, 
delirium, coma, chills, sweating, and diarrhea. The pulse is 
rapid and feeble ; the urine is scanty and high colored, con- 
taining albumin, and the patient's condition is extremely grave. 
This fever, which is known as the secondary fever, continues 
as long as the suppurative process exists. About the time of 
suppuration a peculiar offensive odor is exuded from the body 
of the patient. 

Preliminary Eruption. — A rash sometimes appears before 
the characteristic eruption of variola, generally upon the first 
or second day. This may resemble the rash of scarlet fever 
or measles, usually in triangular forms, which, having been 
discovered by Simon, are known as Simon's triangles. 
They appear upon the inner sides of the thighs, the abdomen, 
the upper part of the chest, and the forearm. In the hemor- 
rhagic variety it occurs as petechias, which may remain for 
some time. 

Varieties. — Discrete, confluent, hemorrhagic, and modified 
smallpox, or varioloid. 

The discrete form shows the pustules separate, with inter- 
vening healthy skin, and is of a milder type. 

In the confluent form the vesicles run together. They 
more rapidly become pustular, and all the symptoms are 
aggravated. 

In the hemorrhagic form two varieties must be differenti- 
ated : (i) Purpura variolosa. — The eruption appears as pe- 
techias. No traces of the true pock can be seen. The skin 
becomes dusky, and purplish rashes appear all over the ex- 
tremities. Hematuria may develop. The temperature may 
be low, but rises just before death. The body of the patient 
emits a terrible odor. The mind usually remains clear. This 
is the variety known as black smallpox. (2) The rash may 
occur in the usual way, but in the vesicular stage hemor- 
rhages occur into the pock. Hemorrhages from other parts 
of the body are also common. 

Complications and Sequels. — These are few in number, 
and are due to secondary infections. Inflammations and sup- 



VARIOLA. 217 

purative processes, such as abscess, furunculosis, and erysipe- 
las, may occur. Diphtheric exudations may be found as a 
secondary affection. There may be bronchopneumonia and 
inflammation of the bones and cartilages. 

Diagnosis. — It is difficult to confound any disease with 
variola when the rash is well developed. No other affection 
presents primary umbilication with consecutive changes from 
macula into papule, vesicle, pustule, crust, and scar. Previous 
to the appearance of the rash it may be impossible to diagnosti- 
cate this condition, but the knowledge of an epidemic should 
prevent blunders in diagnosis. 

Prognosis. — This depends greatly upon vaccination. In 
unmodified smallpox the death-rate varies between 40^ and 
60%. One of the most important factors in the prognosis of 
variola vera (true smallpox) is age. At the extremes of life 
— in the very young and in the very old — it is an extremely 
fatal disease, the prognosis being more favorable between the 
ages of five and fifteen years. Sex is of no importance. In 
alcoholics and drunkards the mortality is extremely high, on 
account of the greater liability to the hemorrhagic or malignant 
varieties. Pregnant women almost invariably abort. The 
discrete variety is more favorable than the confluent. The 
hemorrhagic or malignant variety is almost invariably fatal. 

The severity of the case depends greatly upon the amount 
of the eruption — the greater the eruption, the more serious 
the case. The appearance of the eruption has some weight in 
prognosis, as the more typical the eruption and the more reg- 
ularly it goes through its successive stages, the more favorable 
is the prognosis. 

Prophylaxis. — The prophylaxis against smallpox consists 
in vaccination and rcvaccination. When patients have been 
vaccinated or have had a previous attack of smallpox and 
complete immunity has not been obtained, they contract vario- 
loid or modified smallpox when re-exposed to the disease. 

VARIOLOID, OR VARIOLA MODIFICATA. 

Definition. — This is smallpox modified by previous attack, 
vaccination, or inoculation. The proof consists in the fact that 
if an unprotected person be exposed to varioloid, he will con- 
tract variola vera and not variola modificata. 

Symptoms. — The symptoms are usually the same as in 
unmodified smallpox, except that the initial symptoms are 
generally much milder. The eruption appears earlier, — usu- 



2l8 INFECTIOUS DISEASES. 

ally within thirty-six hours, — and is not nearly so copious, 
there being, perhaps, but three or four, or sometimes from 
twenty to thirty, papules over the entire body. 

Initial Rashes. — Initial rashes (Simon's triangles) occur 
oftener in varioloid than in variola. The eruption goes through 
the stages of macula, papule, and vesicle, rarely, if ever, reach- 
ing the pustular stage, and if pustules do form, they are very 
few in number ; hence, as there is no pus to absorb, secondary 
fever does not take place and the grave symptoms of variola 
vera are averted. 

Complications. — Complications rarely, if ever, occur in 
varioloid. All the symptoms are milder and the disease ter- 
minates sooner. 

Treatment of Variolous Diseases. — Besides vaccination 
as a prophylaxis, complete isolation and disinfection are abso- 
lutely necessary. If the patient be treated at home, all un- 
necessary furniture and other articles should be removed 
from the sick-room. Everything coming in contact with the 
patient, such as wearing apparel, bed-linen, etc., should, if pos- 
sible, be destroyed by fire. It must be remembered that the 
body of a smallpox patient is capable of transmitting the 
disease ; therefore, after death the body should be wrapped in 
cloths that have been soaked in powerful disinfecting solutions, 
and should be removed as quickly as possible. Whenever 
practicable, cremation instead of burial should take place. 

There is no specific treatment. Food, as a rule, is not well 
borne at first, and there may be much vomiting and diarrhea. 
Usually, acid drinks or small particles of ice are grateful to the 
patient. From the beginning of the disease detergent washes 
containing antiseptic solutions should be used for the mouth. 
Many drugs and methods have been used to prevent pitting. 
The most useful method for this purpose is that of covering 
the face with clean cloths saturated with warm water. These 
should be frequently renewed. 

The room should be darkened : the solar light should be 
rigidly excluded. Iced applications should not be applied to 
any part of the body in which the eruption has appeared, as 
cold frequently prevents the pock from maturing. Warm baths 
two or three times daily are of decided benefit to the patient. 
During the time of secondary fever bold stimulation is neces- 
sary, as this is a septic process and must be treated upon these 
principles. If there should be great itching of the skin, with 
irritation, camphorated oil may be used. This has proved 



VACCINIA. 



219 



beneficial in a number of cases. Attention should be given to 
all purulent discharges, which should be speedily removed, as 
their absorption means increased septic disturbance. 

At the onset a laxative is useful, but this should not be 
repeated, as tendency to diarrhea exists. Pain should be 
overcome by small doses of opium, but care must be taken 
with this drug, as it tends to lock up the secretions. Restless- 
ness and insomnia should be treated by trional and sulphonal. 
In the malignant varieties and in severe cases bold stimulation 
is necessary. In convalescence tonics are of service. 

VACCINIA (COWPOX). 

Definition. — A disease always conveyed by artificial inocu- 
lation from animal to man or from one human subject to an- 
other, having an eruption resembling smallpox, from which it 
is protective. 

History. — To Sir Edward Jenner we owe this great discov- 
ery. In the year 1798 he first published the results of his 
experiments, and for many years his conclusions were ques- 
tioned and ridiculed, but the process has now been almost 
universally adopted. As a result of this discovery, the spread 
and the mortality of smallpox have enormously diminished. 

Whether or not vaccinia is a form of smallpox in animals, 
in which the symptoms are milder, is as yet a mooted 
question. 

Vaccine Lymph. — Vaccine lymph consists of two kinds : 
that derived from the heifer, known as animal or bovine 
lymph, and that from the child, known as humanized 
lymph. 

Pathology. — The lesion is limited to the part of the 
skin in which the vesicles develop. At the point of inocu- 
lation in which the vaccine virus is introduced the papillary 
layer of the derma becomes congested, and in from three to 
five days shows symptoms of slight inflammation, followed by 
an exudation of lymph. This increases, and as the layer of 
the epidermis is detached, another layer is lifted forward and 
forms the roof of the vesicle. The vesicle is not unilocular, 
as can readily be determined by pricking it, when it will be 
found that it does not collapse. It bears, in this respect, a 
striking resemblance to the vesicle of variola vera. The lymph 
is at first clear and thin, but soon becomes turbid and opaque. 
At this time a slight depression (umbilication) is seen at the 



220 INFECTIOUS DISEASES. 

top of the vesicle. Desiccation now takes place, particularly 
at the center, and the pock dries up, forming a scab or crust. 
Upon removal of the scab a cicatrix is found beneath, which 
remains permanently. This cicatrix is peculiar, showing well- 
defined margins, being reticulated or foveated — at first red in 
color, in a short time becoming pale and permanent. 

Symptoms of Vaccinia. — These are always produced by 
vaccination, and from two to three days after the introduction 
of the serum no symptoms are noticed except a slight scar, 
due to the instrument used in introducing the lymph. Upon 
the third or fourth day a faint redness appears around the 
point of inoculation, which gradually increases in extent until 
a distinct papule begins to make its appearance, becoming 
more and more prominent. Upon the fifth to the seventh day 
the papule changes to a vesicle, and the lymph that it contains 
is clear and transparent. In a day or two the lymph becomes 
turbid, pearly, and thicker. 

On or about the eighth to ninth day the vesicle has reached 
its height, and is now turbid and yellowish in color, appearing 
as if it contained pus. At this time it is found to be distinctly 
umbilicated. Around the base of the vesicle a well-defined 
inflammatory zone makes its appearance, which becomes red- 
der as it reaches the periphery. This is known as the inflam- 
matory areola. 

Constitutional Symptoms. — The constitutional symptoms 
noted at this time may be slight fever, anorexia, a feeling of 
general malaise, and pain under the arm in the axillary region. 
Upon careful examination it will be found that the axillary 
lymphatic glands are enlarged and painful. From the eleventh 
to the twelfth day the pock fades, becomes opaque, and desic- 
cation is noticed at the center. The areola begins to fade, and 
upon the fifteenth day desiccation is complete, although the 
crust may not fall off until at the end of the third or fourth 
week. Upon the disappearance of the crust a distinct cicatrix 
is found beneath. This scar is at first red and pitted, showing 
radiating bands or striae across it, and in a few weeks becomes 
pale and remains permanent. 

Irregularities. — Irregularities sometimes occur in the de- 
velopment of the pock, and it is necessary to describe one of 
the most frequent, which is known as the "red-raspberry" 
excrescence. About a week after inoculation the papule ap- 
pears, but instead of continuing to the stage of vesicle it 
remains hard and dense, assuming a bright-red color and 



VACCINIA. 221 

looking not unlike a small nevus. It is persistent, and may 
remain for weeks. There is no areola, and upon falling off, 
it leaves no scar. This spurious form is not protective. 

Complications and Sequels. — These may be local or sys- 
temic, but the really serious ones are exceedingly rare. In- 
flammatory complications, which are due to trauma at the time 
of inoculation, may occur, such as a too extensive scarification. 
An abrasion of about one third of an inch in diameter will 
usually be found sufficient. Complications may occur from 
an injury to the pock after its development. Thus, if the roof 
of the pock is broken, an opening is formed through which 
secondary infection may take place. It is not wise to vaccinate 
in areas showing scrofular, tubercular, or eczematous skin 
affections, unless in the presence of exposure or an epidemic. 
The complications, as a rule, consist of lymphadenitis, phleg- 
mons, profuse suppurative processes, dermatitis, etc., and with 
the secondary introduction of pyogenic bacteria may give rise 
to erysipelatous processes. Gangrene of the skin may occur, 
but this is rare, as are also septicemia and pyemia. 

Vaccinal Syphilis. — Bovine lymph, which can now be pro- 
duced in an absolutely pure state, should always be used. If 
humanized lymph must be employed, the physician should be 
careful to obtain it from a child with whose antecedents he is 
absolutely familiar. If a person who has been vaccinated subse- 
quently develops syphilis, if the syphilis be due to vaccination, 
the primary sore or chancre must appear at the point of inocu- 
lation, otherwise it was not due to the vaccination. 

Technic of Vaccination. — A simple thumb lancet is all that 
is necessary for this purpose. After it has been thoroughly 
sterilized, the surface at which the inoculation is to be prac- 
tised should be cleansed with soap and water, then with 
alcohol, and allowed to dry. The skin may be prepared by 
removal of the epidermis through a series of scratches until the 
surface is abraded and a little exudation of serum occurs. 
Avoid drawing blood. Another method is to make four or 
five slight punctures under the skin, rubbing in the lymph, 
and working it beneath the edges of the epidermis by slight 
incisions. It is best always to make two points of inoculation. 
By this means the chance of success is doubled. 

The point of selection for the vaccination is usually the outer 
surface of the arm, at or near the insertion of the deltoid. In 
case of a female child the vaccination may be practised on the 
leg, the point, of inoculation being just below and at the outer 



222 INFECTIOUS DISEASES. 

portion of the tibia. The left arm is usually preferred, because 
the child is mostly carried upon the left arm, in order that the 
right arm may be used for other purposes. Thus, the left arm 
of the child is free and the sore is not rubbed against the body 
of the person carrying it. 

At the present time bovine virus is used almost exclu- 
sively. 

As staphylococci are almost invariably present, it has been 
found that by mixing the lymph with sterilized glycerin (40^), 
sealing it up in tubes and putting it in ice-boxes for several 
weeks, these organisms are destroyed. The stables in which 
the cows are kept are rendered as clean as possible, all the 
animals being subjected to the tuberculin test. After the virus 
is obtained the animal is killed, and an autopsy is held to see 
that it is free from tuberculosis. 

A healthy calf about six months old is chosen for the pur- 
pose. It is laid upon the table, and the abdomen and inner 
parts of the thighs are shaved and given an antiseptic toilet. 
A sterilized glycerinated virus is rubbed over the scarified 
place. The animal is well fed and watched for five days, then 
thoroughly cleaned again, and the crust or scab removed with 
a spoon curet. The mass is weighed and dried, ground up 
with sterilized glycerin, sealed in glass tubes, and placed in an 
ice-chest for five weeks. These glass tubes usually come ten 
in a box. The box also contains a rubber bulb or tube, which 
is attached to the glass after the ends are broken off, when it 
is desired to use the virus. The virus is obtained from the 
glass by squeezing the rubber tip or blowing through the rub- 
ber tube. 

Humanized Virus. — Humanized virus is somewhat quicker 
in its action, and the constitutional symptoms are said to be 
milder. It is desirable not to vaccinate a child before the third 
month after birth, for if it be syphilitic, the symptoms will have 
shown themselves by this time. 

Every one is susceptible to vaccinia, although this varies in 
individual cases. Vaccination should be practised and re- 
practised until a typical scar results. A child should be vac- 
cinated, as stated, at three months after birth, again at the end 
of seven years, and again at puberty, and always after expos- 
ure to and in the presence of an epidemic of smallpox. 



VARICELLA. 223 



VARICELLA. 



Definition. — An acute, infectious, contagious disease of 
childhood, characterized by a vesicular eruption and mild 
constitutional disturbances. The disease is highly conta- 
gious. 

Synonym. — Chickenpox. 

Etiology. — This disease bears no relation to variola, and 
one attack while conferring immunity from itself, does not pro- 
tect from smallpox. 

Exciting Cause. — Not known. The poison is transmitted 
from the sick to the well by contact, and to a short distance 
through the air, and is carried by fomities. The disease 
usually occurs in epidemics. Sporadic cases are rare. 

Predisposing Cause. — Age is the principal predisposing 
cause. It is most common between the fifth and tenth years 
of life, and is comparatively rare in adults. - 

Period of Incubation. — The period of incubation is usually 
given as from ten to fifteen days. It may be slightly longer 
or shorter than this. 

Symptoms. — Prodromes are absent as a rule. The dis- 
ease is ushered in by a mild chill. The appearance of the 
eruption marks the beginning of the disease. The exanthem 
shows itself as a small reddish point or papule, which in a 
very few hours becomes a vesicle. It is slightly elevated above 
the skin, rather than having the appearance of being under the 
skin. The vesicles are thin and transparent, and from one- 
eighth to one-fourth of an inch in diameter. The contents 
are at first clear and transparent. There is usually no areola. 
In the course of a few hours the vesicle becomes milky and be- 
gins to shrivel, with a depression at the top, from absorption 
of its contents (secondary umbilication), corresponding to the 
same condition in smallpox. This results as a yellowish- 
brown crust that, in about ten days from the beginning of the 
attack, and even before this, separates, leaving a more or less 
well-defined scar, which, in some cases, especially upon the 
face, remains permanently. The pox may appear upon the 
face, neck, scalp, wrists, and some parts of the body. It may 
be generalized and then found particularly upon the trunk. It 
may appear upon the cheek, tongue, palate, and even upon the 
conjunctiva and, occasionally, upon the genital organs. Con- 
stitutional symptoms are usually absent, and when present, are 
of an exceedingly mild type. Occasionally, the superficial 



224 INFECTIOUS DISEASES. 

lymphatics may be enlarged. If the vesicles are scratched or 
injured, they become painful. 

Complications. — Complications are rare. Occasionally, 
erysipelas results from secondary infection. 

Diagnosis. — The diagnosis depends upon the appearance 
of the eruption upon the first day, with or without mild consti- 
tutional symptoms. 

Differential Diagnosis. — Occasionally, mild grades of vari- 
oloid may be mistaken for chickenpox. In doubtful cases 
occurring in adults the scars of vaccination should be looked 
for. If well-defined scars be present, varioloid may be excluded. 
In varioloid the eruption does not come out until after from 
thirty-six to forty-eight hours of mild constitutional symptoms. 
In varicella the eruption marks the first manifestations of the 
disease. The knowledge of an epidemic should be important 
in differentiating the two affections. 

Prognosis. — Almost invariably favorable. 

Treatment. — Patient should be put to bed and given a bland 
diet. A gentle purge at the onset is of use. The lesions on 
the face should have protection from pricking and scratching : 
several layers of collodion may be painted over them for this 
purpose. In young children the hands should be enveloped 
in mittens or bandages. Isolation is not necessary, nor is dis- 
infection, except by fresh air, as the disease is insignificant and 
so contagious that it is better for a person to have it in child- 
hood than in adult life, when the disease is likely to be 
severer. 

ERYSIPELAS. 

Definition. — An acute, febrile, contagious disease, charac- 
terized by inflammation of the skin, with constitutional symp- 
toms. 

Synonyms. — St. Anthony's fire ; "the rose." 

Etiology. — One attack does not confer immunity, but rather 
predisposes to other attacks. It rarely occurs in epidemics. 
It may appear as a local inflammation without constitutional 
implication. It is placed in the group of eruptive diseases on 
account of its having a specific eruption with constitutional 
symptoms and running a definite course. 

Predisposing Causes. — Occurs at all seasons of the year 
and in all parts of the world. Sex has no influence. It may 
occur at any period of life, but is especially liable to develop in 
debilitated and cachectic persons and in the course of chronic 



ERYSIPELAS. 22 5 

pulmonary tuberculosis. Modern pathology teaches that ery- 
sipelas is due to the entrance into the organism of toxic agents 
that produce inflammatory conditions of the skin through an 
open wound ; hence this disease is liable to occur in the puer- 
peral state. It has sometimes resulted from a small crack in 
the skin at the angle of the nose or at the mouth, or from a 
scratch upon the face ; from the piercing of the ears for ear- 
rings or from the ulceration about a carious tooth. In some 
instances the point of entrance of the specific agent can not 
be found. 

Exciting Cause. — This disease is due to the streptococcus 
erysipelat'os of Fehleisen. (For a description of the germ see 
p. 101.) Since the discovery of this germ the division into 
idiopathic erysipelas must be entirely abandoned. 

It has not been shown to be transmissible by the air, having 
occurred without obvious traumatism, abrasions, or inocula- 
tions, and may enter the organism by the respiratory surfaces. 
Most cases occur in the spring of the year. Occasionally, a 
house epidemic has occurred. 

Pathology. — When the specific germ gains entrance into 
the tissues, it produces the phenomena of severe inflammation. 
These changes may extend to the subcutaneous tissues. Occa- 
sionally, the inflammatory changes will go on to the point of 
suppuration. The inflammatory process is usually circum- 
scribed. Postmortem appearance will reveal, besides the local 
lesion, evidences of granular degeneration of the internal 
organs, such as the heart, kidney, and liver. These changes 
are, as a rule, produced by the toxins, the organism rarely 
gaining access to the blood-corpuscles. In such an event 
suppurative changes are produced. A marked leukocytosis 
of an inflammatory character is present. 

Period of Incubation. — From three to seven days ; in arti- 
ficial inoculation, from fifteen to sixty hours. 

Symptoms. — The disease usually begins with a chill, w T hich 
may be mild or severe, and is followed by the development 
of the eruption. With this there are usually gastric distress 
and some febrile reaction (the temperature not being charac- 
teristic), with the signs of an irritative, itchy, swollen skin at 
the point at which the eruption begins. There are heat, 
tension, and burning in the part. The eruption shows a 
decided elevation with a distinct prominent margin, red and 
puffy in the center. It is irregularly circumscribed, and there 
is an abrupt descent to the level of the surrounding skin. The 
i5 



226 INFECTIOUS DISEASES. 

involved area is discolored, of a bright crimson color, and 
glossy in appearance. 

The skin is hot and tender, but firm and smooth. For two 
or three days the area extends uniformly but irregularly ; the 
margins, however, being always abrupt, well-defined, and 
circumscribed. In mild cases, after two or three days the 
eruption may become stationary and the process undergo 
resolution, with a remission in the fever, desquamation of the 
inflamed area, subsidence of the edema, and the color changing 
from a bright red to a bluish purple or light brown. The 
desquamation occurs in scaly masses. In mild cases the erup- 
tion may show no tendency to spread, but may remain where 
it first appeared, involving the whole face or side of the scalp, 
and terminating in recovery in from two to three weeks. In 
the severer cases the inflammation spreads over wider surfaces 
and invades the adjacent skin, leaving the portions in the cen- 
ter pale and red and undergoing desquamation. 

If bullae are formed, serum is thrown out under the epi- 
dermis, or if the inflammation has been severe, true blisters 
occur. The fluid in such cases is limpid, of a straw color, and 
may be purulent. As resolution takes place crusts are formed 
that gradually break down. In malignant cases areas of gan- 
grene form, the skin repairing by sloughing and cicatrization. 
If the erysipelas travels over a considerable area, disappearing 
at one point and appearing at another, it is known as " erysip- 
elas ambulans" or "wandering erysipelas." This is much 
more serious, and the affection is likely to terminate fatally, 
although the process may be prolonged over a series of weeks. 

In severe cases in which the affection appears upon the face 
the eyes are closed, the lips project, the ears are shapeless and 
cushiony, the nose is deformed, the cheeks encroaching upon 
it, and secretions may collect at the corners of the eyes, mouth, 
or nose. The whole face is painfully distorted and deformed. 
The tongue is coated with a yellowish fur, becoming dry and 
glazed and of a reddish hue. In severe cases marked nervous 
symptoms develop, delirium, coma, subsultus tendinum, and 
carphology, and the temperature may rise to 106 F. or 
higher. 

In fatal cases hemorrhages take place in the blebs upon the 
skin, and gangrene makes its appearance. This may occur in 
infants, in the aged, in those subject to chronic alcoholism, 
and in cachectic individuals. 

The disease commonly starts from the point of the ear, tip 



ERYSIPELAS. 22? 

of the nose, from a point of vaccination, or from ulcers upon 
the lower extremities. The bowels are usually constipated. 
The urine has the character of febrile urine, and even in mild 
cases true albuminuria occurs early in the course of the dis- 
ease. 

Surgical Erysipelas. — Surgical erysipelas rarely occurs in 
these days of antiseptic methods. 

Complications and Sequels. — Complications and sequels 
are not numerous. Albuminuria occurs in serious cases, and 
always when the temperature is high. Uremia has occasion- 
ally been noted. After erysipelas of the scalp there is alope- 
cia, and seborrhcea sicca may occur, which gives rise to per- 
manent baldness. Abscess occurs, and lymphangitis has been 
noted. Arthritis may result from the extension from the skin 
to the joint tissues. Peritonitis and malignant endocarditis 
have been seen as sequels. 

Diagnosis. — Depends upon the occurrence of the eruption 
with well-defined margin, showing tendency to spread, occur- 
rence of fever, and constitutional symptoms. 

Prognosis. — In simple uncomplicated cases occurring in 
those in previous good health, prognosis is favorable. 

Prognosis should be regarded as serious when erysipelas 
occurs as a complication of any other malady or from surgical 
accidents or in the puerperal state. It is always serious in 
cachectics and in alcoholics. 

Treatment. — Prophylaxis is that of the infectious diseases 
in general. In hospitals erysipelas is isolated and treated in 
separate wards, as the disease is mildly contagious. Treat- 
ment should be directed to the alleviation of the principal 
symptoms. Free purgation is useless and unsafe, but gentle 
laxatives at the onset are of advantage. 

Water, especially cold water, should be liberally adminis- 
tered to the patient, and cold spongings, especially if the tem- 
perature is high, are of distinct advantage. 

For the eruption the best treatment consists of iced cloths, 
frequently renewed, kept over the eruption. An ointment of 
ichthyol and lanolin is also used for this purpose, but this is 
smeary and the benefit derived is questionable. Collodion 
may be painted over the eruption with good result. There is 
no specific treatment. 

Tincture of chlorid of iron in full doses is the general 
method of treating erysipelas. It is, however, questionable 
whether any good has been obtained from its use. In severe 



228 INFECTIOUS DISEASES. 

cases the hypodermic use of pilocarpin, as first advised by 
Da Costa, is of distinct benefit, if cautiously used. The physio- 
logic effect of pilocarpin should be obtained, but a stimulant 
should be administered at the same time, on account of the 
depressing effects of the pilocarpin on the circulation. When 
nervous symptoms become prominent, or in the aged or cachec- 
tic, bold stimulation is necessary. Alcohol is best for this 
purpose. If the pain be severe, the hypodermic injection of 
morphin should be resorted to. Systematic and liberal admin- 
istration of nourishment must be insisted upon in severe cases. 
Antistreptococcic serum may be beneficial, and may be resorted 
to, especially in malignant cases. 



FEVERS WITH MARKED LOCAL MANIFESTA- 
TIONS. 

CROUPOUS PNEUMONIA. 

Definition. — An acute, infectious, febrile disease, with a 
characteristic local pulmonary lesion and marked constitutional 
symptoms. 

Synonyms. — Lung fever ; lobar pneumonia ; fibrinous 
pneumonia ; pleuropneumonia ; pneumonitis. 

Etiology. — Predisposing Cause. — Climate is a predisposing 
cause, pneumonia being more prevalent in warmer than in 
colder climates. It may occur at any season of the year, but 
especially in the winter and early spring. Nine-tenths of the 
cases of pneumonia of the aged occur between November and 
May. Sudden changes in the temperature have greater influ- 
ence on the production of pneumonia than prolonged steady 
cold weather. Damp weather and rainy seasons do not pre- 
dispose. 

It occurs at all ages, and is the most fatal of all diseases 
after sixty. The male sex suffers to a greater extent than the 
female, probably due to exposure and occupation. Depressing 
influences, both physical and mental, are said to be predis- 
posing causes. Previous disease is important, as pneumonia 
is often the terminal event in the cachectic and alcoholic indi- 
vidual. It is a common sequel in acute diseases, such as the 
malarial and other infectious fevers. 

Exciting Cause. — The specific organism is the diplococcus 
pneumoniae. (For a description see p. 103.) Other organisms 



CROUPOUS PNEUMONIA. 229 

have been found associated with croupous pneumonia, such 
as Klebs-Loffler bacillus, staphylococcus, bacillus typhosus, 
bacillus coli communis, and bacillus of influenza. It is only 
within the last decade that pneumonia has been widely recog- 
nized as an infectious disease, up to that time having been re- 
garded generally as a local inflammation of the lungs. 

Period of Incubation. — Period of incubation is unknown. 

Pathology. — This form of inflammation of the lungs affects 
most generally a lobe, or more than a lobe, sometimes affect- 
ing the entire lung; hence the name, lobar pneumonia. The 
most frequent site of attack is, first, the right base ; next, the 
left base ; both bases and the apices less frequently. The 
condition is a process of acute inflammation, the stages gradu- 
ally merging one into the other, and, for the purpose of clear- 
ness in description, the stages are defined separately. 

The pathology of croupous pneumonia is divided into three 
stages: first, engorgement ; second, consolidation ; third, reso- 
lution. The infectious irritant lodges in the lung, and produces 
its effects in the air vesicles. The introduction of the infec- 
tion is imported into the lung through the respiratory tract, 
The diplococcus of pneumonia being in many instances 
normal in the saliva, the mode of infection is, therefore, easily 
traced when the system is in such a condition as to favor the 
growth of this organism. 

In the stage of congestion the blood-vessels are found 
dilated, the lung becomes red, and when the affected area is 
placed in water, it floats at a deeper level than normal tissue. 
Microscopically, it will be found that in the stage of engorge- 
ment the blood-vessels are dilated, but little or no exudate is 
noticed in the air vesicles. 

The epithelium lining the air vesicles becomes granular, 
swells, and is shed of its basement membrane. Gradually, the 
exudate forms in the air vesicles, giving rise to the stage of 
consolidation, the first part of which is termed red hepatization, 
so called because it resembles liver structure. In this stage 
the affected area is completely consolidated, and when placed in 
water, it sinks. There will be complete absence of crepitation. 
Microscopically, it will be found that the exudate in the air 
vesicles is composed of a large amount of fibrin, leukocytes, 
red blood-cells, and a few epithelial cells. The specific micro- 
organism is found in this exudate. The blood-vessels are still 
dilated and tortuous. This exudate, as a rule, contracts some- 
what, and probably by the force of gravitation seeks the de- 



23O INFECTIOUS DISEASES. 

pendent portion, so that it will appear free from the walls of 
the alveoli except at the lowermost portion. The large 
amount of fibrin present has given to this condition the name 
of fibrinous pneumonia. 

The inflammatory exudate soon undergoes fatty degene- 
ration. The leukocytes increase in number, and this change 
gives the consolidated area a gray color, called gray hepati- 
zation. 

The stage of consolidation gradually merges into the stage 
of re solution y this being brought about by further degeneration 
and softening of the exudate, a large part of which is carried 
away by lymphatics and the blood, some portion being ex- 
pectorated. The epithelial cells are again reproduced from the 
bronchial epithelium, gradually extending into the alveoli. If 
recovery occurs, the lung entirely returns to its normal con- 
dition, making it impossible to say whether it has ever been 
affected by this acute inflammatory process. 

The stage of resolution may be somewhat delayed. This 
is known clinically as " delayed resolution." Instead of reso- 
lution, abscess formations may rarely occur, or, in extreme 
cases, entire death of the infected part, producing gangrene. 
The inflammatory process may become more or less chronic, 
fibrid pneumonia resulting. Tubercular infection may arise 
during or after this inflammatory process. 

If the irritant reaches the pleura, which it does in the ma- 
jority of cases, an acute fibrinous inflammation is set up in this 
serous membrane, the changes being similar to those just 
described ; hence the synonym, pleuropneumonia. The bron- 
chial tubes show a slight amount of inflammatory change. 
This is probably secondary to the alveolar inflammation. The 
heart muscle shows cloudy swelling, with hypertrophy and 
dilatation of the right ventricle and auricle. From extension 
of the inflammatory process the pericardium may be acutely 
inflamed. Other internal organs may also evince evidences of 
cloudy swelling. 

Symptoms. — The symptomatology varies in individual 
cases, presenting marked differences in the onset and course 
of the disease. This has led writers to divide the cases into 
the " sthenic " and " asthenic " varieties. On the one hand, the 
symptoms may point to marked pulmonary disturbance, 
whereas on the other hand they may be obscure, and the 
diagnosis can be made with difficulty and only after a careful 
physical examination. The disease usually begins with a 



CROUPOUS PNEUMONIA. 



2 3i 



marked, well-defined, severe chill, which may come on at any 
time of the day, but more often at night. In scarcely any 
other acute infectious disease is the chill so prolonged and so 
severe as in croupous pneumonia. 

In other types of the disease, especially in pneumonia of the 
aged and in alcoholics, the chill may not be present at all. 
Following it there is an abrupt rise in the temperature, ranging 
from 103 ° F. to 1-05 ° F., attaining its maximum early — often at 
the end of twenty-four hours or early on the second day. Fol- 
lowing this there is pain, referred to the region of the nipple 
upon the affected side. The pain is due to the involvement 
of the pleura, which takes place in the majority of the cases. 



Temp, 
IF. 



Dav of Disease 



IO 



Temp. 



104 
103 
102 
101 
IOC 
99 
98 



I 




5§ 



S 



40 



-38 




Fig. 31. — Temperature-curve of croupous pneumonia. J. L., twenty-seven years old 
(Philadelphia Hospital), March 19, 1900. 



If the inflammatory conditions do not reach the periphery of the 
lung, as in central pneumonia, the pleura is not affected and 
the pain does not occur. Coincident with the pain there is 
marked dyspnea. The appearance of the face is characteristic : 
there is an anxious look, a flush upon one or both cheeks, the 
eyes are bright, and the alae of the nose deviate with each 
respiratory act. 

Herpes may be present at the nose or at the lips. Cough 
is now present, which at first is suppressed on account of the 
severe pleural pain, the patient frequently lying upon the 
affected side. The sputum early is scanty and viscid, and may 
be rusty. If rusty sputum does not occur early, it will prob- 



2 $2 INFECTIOUS DISEASES. 

ably appear later in the course of the disease, especially in 
well-marked cases. 

Nervous symptoms are common — headache, restlessness, 
and in some cases delirium, although these are not constant 
symptoms. Backache, anorexia with great thirst, constipation, 
scanty and febrile urine, also occur. This stage usually lasts 
about four days, resolution occurring between the fifth and the 
eighth day ; occasionally earlier and sometimes later. 

In typical cases the temperature falls abruptly by crisis, 
usually upon one of the odd days of the disease. In other 
cases lysis occurs. During the entire course of the disease 
there are well-marked physical signs, which may continue for 
several weeks, even after resolution has taken place. 

Description of Special Symptoms. — Temperature. — The 
temperature rises abruptly to 103 F. or 105 ° F. and even 
higher, attaining its maximum early. The morning remissions 
and evening exacerbations amount to about one degree, the 
temperature in ordinary cases running a subcontinuous course. 
Occasionally remissions occur, the temperature falling from 
two to four degrees, but not reaching the normal. These are 
known as pseudocrises and may precede the true crisis. The 
true crisis may be preceded by a rise in the temperature, known 
as the precritical rise. The crisis occurs usually upon the 
fifth, seventh, or ninth day of the disease, and may take place 
at night, the temperature reaching the normal or subnormal 
ranges. Copious sweating takes place at this time, or there 
may be profuse diarrhea, and large quantities of urine may be 
voided. 

Defervescence occasionally comes on by lysis, especially in 
the asthenic types. An elevation of temperature occurring 
after defervescence is due to complications. In pneumonia 
affecting an apex hyperpyrexia is very apt to occur. 

Respiration. — The respirations may number from thirty to 
forty a minute : they are more frequent in children and in 
nervous patients. The ratio of respiration to pulse, which in 
the normal condition is one to four, may be from two to four, 
or even one to one. The breathing is painful, shallow, and 
partly suppressed, especially if the pleura be affected ; the 
pain lasts several days from the onset of the disease. Cough 
may be frequent and distressing, but in the asthenic cases, in 
the aged, and in alcoholics, as well as in central pneumonia, it 
may be entirely absent. It is unproductive, short, and dry at 
first, sputum showing itself in a day or two. 



CROUPOUS PNEUMONIA. 233 

Sputum. — The sputum varies according to the stage of the 
disease. It is usually moderate in quantity, but may be absent 
altogether. It is at first glairy, mucous, viscid, and frothy, and 
may be stained with blood. In the stage of hepatization it 
becomes gelatinous and very tenacious, so that if it be expecto- 
rated into a cup and this be inverted, the sputum will cling to 
the sides of the vessel and not fall. It shows various shades 
of red, small streaks of blood being; scattered through it, look- 
ing like iron rust ; hence the name, " rusty sputum." This is 
a characteristic phenomenon of this disease. In severe cases 
in which the hemorrhagic element is profuse, especially in 
alcoholics, the sputum is more fluid, having the character of 
prune-juice", and is therefore called "prune-juice" expectora- 
tion. Microscopically, it contains white and red blood-cor- 
puscles, degenerated and pigmented alveolar epithelium, and 
bacteria, in which the pneumococcus is usually found to be 
present. The sputum may contain fibrinous casts of the 
bronchi, and in the stage of resolution is thick, of a yellow 
color, and of a mucopurulent character. 

Pulse. — The pulse is related to the height of the fever, being 
from 120 to 130, and in children and asthenic cases it is even 
more rapid than this. The pulse-rate falls with crisis, and 
may be as low as 50 a minute. Early in the disease the 
pulse is full and strong, but later it becomes compressible 
and irregular. 

Nervous Symptoms. — Nervous symptoms are present in the 
old, the very young, and in drunkards. Headache is common, 
and there may be a mild delirium at night or the mind may 
remain clear during the entire attack. In cases with high 
temperature in which the apex is affected, delirium is a promi- 
nent symptom. In children convulsions may occur, the clin- 
ical picture closely simulating meningitis. In drunkards deli- 
rium tremens commonly takes place. 

Digestive System. — Anorexia is complete, and there is much 
thirst. Vomiting is commonly present in children ; constipa- 
tion is the rule, but diarrhea may be present from the onset. 
If it appear late in the disease, it is an unfavorable symptom. 

Urine. — The urine shows the characteristics common to the 
fevers. It is scanty, of a high specific gravity, and in one- 
third of the cases contains albumin. During the course of 
the disease the urates are generally increased, but the chlorids 
are diminished. This condition is considered diagnostic by 
some authorities. 



234 INFECTIOUS DISEASES. 

Blood. — The blood shows the presence of leukocytosis. 
This may be as high as 20,000 to 50,000 in a cubic 
millimeter. 

The patient commonly lies upon his back or upon the 
affected side, the nostrils expanding with each inspiration and 
the cheeks are flushed on one or both sides. 

Jaundice, if present, and occurring early, may be due to 
catarrh of the gastro-intestinal tract or congestion of the liver ; 
if late, it is hemahepatogenous in origin. Febrile jaundice, 
according to Leube, is always suspicious of croupous pneu- 
monia. Herpes of the nose and lips is common, occurring in 
at least one-third of the cases, and usually early. Sudamina 
show themselves when sweating appears. 

Physical Examination. — Inspection. — Upon inspection 
the respiratory action of the affected side is restricted, usually 
without bulging. If bulging occur, it is most probably due 
to an intercurrent pleurisy with effusion. 

Palpation. — Upon palpation over the affected area there is an 
increase of vocal fremitus. This may at times be absent, if the 
main bronchus be occluded by tough masses of the exudate or 
if pleural effusion be present. 

Percussion. — At the beginning of the attack percussion 
over the area of the lesion is clear, since the process of exu- 
dation has yet scarcely begun. When exudation takes 
place, impairment of the resonance occurs, which may go on 
to complete dullness. If pleural effusion be present, there 
may be flatness. Above the area of consolidation " Skodaic 
resonance " is found upon percussion. As resolution occurs 
the dullness gradually gives place to impairment of resonance, 
and finally normal pulmonary resonance is again encountered. 

Auscultation. — These phenomena depend, first, upon the 
presence of an exudate that is yet fluid, and, second, upon the 
presence of an exudate that has undergone coagulation, and 
thus converted a portion of the lung or the entire lung into a 
dense, practically airless tissue. At the beginning of the dis- 
ease there are large and small bronchial rales that are not to 
be distinguished from those occurring in bronchitis, which is 
indeed an associated condition. In addition to this, in most 
instances early in the attack, the crepitant rale occurs, which 
is characteristic of croupous pneumonia. In the stage of con- 
solidation the crepitant rale disappears as the vesicular struc- 
ture of the lung becomes entirely filled with the exudate. The 
rale reappears in the stage of resorption (third stage). (For 



CROUPOUS PNEUMONIA. 235 

description of Crepitant Rale, see p. 74.) Increased vocal 
resonance is present in the stage of consolidation. 

The breathing, which at first is bronchovesicular in charac- 
ter (harsh respiration), later becomes bronchial in the stage 
of consolidation, and as absorption takes place the crepitant 
rale and a mixture of bronchial rales reappear, and are 
known as the " crepitus redux." Associated physical signs 
upon auscultation relate to the pleura. Friction sounds, more 
or less distinctly audible, may be present with friction fremitus. 

When pleural effusion occurs, the physical signs relating to 
this condition are present. If pleural effusion be suspected, 
exploratory puncture should be made as early as possible. 

Varieties. — Pneumonia in Children. — Croupous pneumo- 
nia is by no means a rare affection in childhood. The initial 
chill is usually absent. Vomiting is more common than in the 
adult. Nervous symptoms may be marked from the onset, 
such as drowsiness, delirium, and convulsions, which may com- 
pletely mask the physical signs, as rusty sputum is rare in chil- 
dren, and, if it occurs, is usually swallowed. The temperature 
in childhood is high. The disease commonly affects the apex. 

Pneumonia in the Aged. — This may begin as a typical 
pneumonia, but as a rule the onset is more gradual. Pro- 
dromes may be present ; rusty sputum is rare, and the tem- 
perature is not so high. 

Pneumonia in Alcoholics. — Pneumonia is of common 
occurrence after a debauch or in individuals subject to chronic 
alcoholism. Delirium tremens may appear early, and the 
accompanying nervous symptoms completely mask the other 
phenomena of the disease. There is no cough, pain, nor 
shortness of breath. The temperature may be but slightly 
elevated or even subnormal, and it is only upon careful phys- 
ical examination of the chest that a diagnosis can be made. 

Pneumonia with Slight or Central Pulmonary Lesions. 
— The onset and subjective symptoms are definite and well 
marked, but the physical signs may be few or absent alto- 
gether. If the lesion occur in the interior of the lung and 
does not reach the periphery, the typical symptoms may be 
present, but the physical signs may be entirely wanting. The 
examination of the sputum in such cases may be important. 
This condition is known as central pneumonia. 

Typhoid Pneumonia. — This name is misapplied by practi- 
tioners to two varieties of cases : First, pneumonia of the 
asthenic variety, occurring with the so-called "typhoid" 



236 INFECTIOUS DISEASES. 

state ; second, to pneumonia occurring as a complication 
in enteric fever. The term typhoid pneumonia had better not 
be used, as it is misleading and not at all distinctive. 

Pneumonia Occurring as an Intercurrent Affection in 
Chronic Diseases. — This is common in nephritis, diabetes, 
locomotor ataxia, and other diseases of the spinal cord. It may 
also complicate tuberculosis and chronic bronchitis. Occurring 
in the course of chronic diseases, it retains its characteristic phe- 
nomena and should be regarded as an independent affection. 

Complications. — Complications in pneumonia are few. 
Bronchitis and pleurisy should be regarded as accompanying 
the disease. Pleurisy with effusion and empyema occasion- 
ally complicate this disease. Pericarditis occurs as a compli- 
cation, especially in left-sided pneumonia, particularly from 
extension due to the disease of the pleura. Endocarditis, es- 
pecially malignant endocarditis, may be a complication. Per- 
ipheral neuritis is rare, as is also parotid bubo. Hemorrhages 
occasionally manifest themselves in the alcoholic variety. 

Diagnosis. — This rests upon the suddenness of the onset, 
with a characteristic chill, high temperature, nature of the 
sputum, pain, herpes, and the defervescence by crisis. 

Differential Diagnosis. — This disease must be differentiated 
from pleural effusions and bronchopneumonia. 

Crcnipous Pneumonia. Pleural Effusion. 

Sudden onset, with chill and high fever. Onset moderate ; no chill ; slight fever. 

Dullness on percussion. If it occur at Flatness upon percussion always at the 

upper part of the lung the lower por- base extending upward. 

tions are clear. 

Vocal fremitus and vocal resonance in- Vocal resonance and vocal fremitus 

creased. absent or diminished. 

Bronchial breathing. Absent breath-sounds. 

Crepitant rales, before and after stage Friction sound may be present early in 

of dullness. the disease, disappearing when effu- 
sion takes place. 

No displacements of organs. Marked displacement of organs — heart, 

liver, Traube's semilunar space. 

Rusty sputum. Sputum, if present, never rusty. 

Crisis upon fifth, seventh, or ninth day, Lysis, no critical discharges, and dura- 

with critical discharges. tion of the disease more chronic. 

Croupous Pneumonia. Bronchopneumonia. 

Primary disease, with sudden onset. Always secondary to bronchitis. 

Often unilateral. Always bilateral. 

Affecting young, robust adults. Occurs at the extremes of age, and 

never affects young adults. 

Typical temperature. No typical fever-curve. 

Rusty sputum. Sputum as in bronchitis, never rusty. 

Crepitant rales and crepitus redux. Subcrepitant rales. 

Duration brief, ending by crisis. Duration prolonged, ending by lysis. 



CROUPOUS PNEUMONIA. 237 

Prognosis. — In the robust type the prognosis is favorable, 
most cases ending in recovery. At the extremes of life and in 
alcoholics the prognosis is grave. When pleurisy with effu- 
sion occurs, the prognosis is more unfavorable. Endocarditis 
and pericarditis increase the gravity of the case. An intense 
toxemia is very serious. When a number of cases appear in 
the same house or in a restricted locality in which unhygienic 
surroundings prevail, the prognosis is unfavorable. The 
mortality from croupous pneumonia is generally estimated 
at about 20%. 

Treatment. — There is no prophylaxis, as the period of in- 
cubation is unknown. One attack is not protective : on the 
contrary, it rather predisposes to other attacks. In young 
adults, with sudden engorgement of the right heart and signs 
of pulmonary congestion and edema, with full, hard pulse, 
blood-letting is not only permissible, but even necessary to 
save life. In the old and in the alcoholic variety this is a 
dangerous procedure. 

A room with good ventilation should be selected. The 
food should be simple and of the ordinary variety given in 
fevers. It should be sparingly given early in the attack, 
and freely during convalescence. A laxative medicine at 
the onset is of use. The fever usually does not require 
treatment, as the disease is a short one. Cold sponging 
may be practised morning and evening. If hyperpyrexia 
occur, the cold bath may be resorted to. The modern 
antipyretic analgesics must be used with caution. For the 
pain, several ice-bags should be applied to the affected side, 
or moderate doses of opium in some form given, such as 
Dover's powder in doses of from three to five grains, which 
may be administered every three or four hours until the pain 
is relieved or light somnolence occurs. 

Poultices and the cotton jacket are of exceedingly doubtful 
utility, and prevent the necessary and systematic examinations 
of the chest. Alcohol may be given in small doses from the 
beginning of the attack, to control the nervous symptoms, and 
especially in the asthenic forms. Strychnin as a cardiac and 
respiratory stimulant is useful, and may be given either by the 
mouth or hypodermically. For sleeplessness, especially in 
the alcoholic variety, chloral should not be used. Trional 
and sulphonal are safer drugs. 

If there be evidences of contraction of the peripheral circu- 
lation, the nitrites, especially nitroglycerin, are useful. Oxygen 



238 INFECTIOUS DISEASES. 

inhalations should be administered in all severe cases. Blisters 
should not be applied at the height of the disease, and should 
only be resorted to in cases of delayed resolution. 

Convalescence is usually rapid, tonic treatment being, there- 
fore, unnecessary. Complications must be treated as in any 
other affection, and upon their own merits. 

ACUTE RHEUMATIC FEVER* 

Definition. — An acute febrile disease, characterized by in- 
flammation of the joints, acid sweats, and a tendency to in- 
volvement of the serous membranes, particularly of the joints 
and the heart, with constitutional symptoms. 

Synonyms. — Acute inflammatory rheumatism ; rheumatic 
fever. 

Etiology. — The disease shows a hereditary tendency, and in 
the new-born and in young children it is more likely to occur 
in the female, in the proportion of five to one. In later life 
the male sex is more liable, probably due to increased expo- 
sure. Age is an important predisposing factor, the disease 
occurring particularly in young adults ; it may, however, 
arise at any age. It is more prevalent in cold and damp cli- 
mates, although it is not infrequent in the tropics. It is an 
unknown disease in some parts of Belgium. 

Exposure to cold and injuries to the joints are not particu- 
larly predisposing causes. On the other hand, changes in the 
weather and prolonged exposure to such changes are impor- 
tant factors. Acute rheumatic fever attacks all classes, the 
well-to-do and the poor suffering equally. 

Occupations such as those of coachmen, drivers, scrubbing 
women, etc., that require continual long exposure to cold and 
wet, predispose. 

The specific cause of acute rheumatic fever is by no means 
settled. By some it is still regarded as a mere inflamma- 
tion of the joints. However, the view that the disease is an 
infectious one is constantly gaining ground. Three principal 
theories have been entertained as to the causation of this dis- 
ease. These are : 

1. The Chemic Theory. — It is held that acute rheumatic 
fever may be due to the excess of lactic or uric acids in the 
tissues. This theory has now been abandoned. 

2. The Nervous Theory. — This was first advocated by J. 
K. Mitchell, on account of the fact that joint implication 



ACUTE RHEUMATIC FEVER. 239 

occurs in a great many of the diseases of the nervous system, 
such as myelitis, locomotor ataxia (Charcot's joints), chorea, 
etc. 

3. The Infectious Theory. — This was advocated by Heuter, 
and numbers of modern clinicians are following his views. 
Various germs have been found from time to time in the blood- 
serum and in the synovial membranes, but no constant variety 
has been found uniformly present. 

The following reasons make it extremely likely that acute 
rheumatic fever is an infectious disease : The disease occa- 
sionally occurs in an epidemic form ; it is self-limited ; it mainly 
affects the young ; severe symptoms and complications occur 
as in other infectious diseases, such as hyperpyrexia, endo- 
carditis and pericarditis, pleurisy, and pneumonia ; there is a 
marked tendency to leukocytosis, albuminuria, and anemia ; 
rashes not infrequently occur ; many infectious diseases also 
combine joint affections, such as pyemia, scarlatina, cerebro- 
spinal fever, etc. ; the toxemia is best explained by the variety 
of different symptoms, and relapses occasionally take place. 

Pathology. — There are no constant lesions found after 
death. Most patients recover without permanent lesions in the 
joints, and unless cardiac complications follow, are wholly free 
from pathologic remains. The joints during the acute stage 
show some degree of hyperemia, especially pronounced in the 
synovial membranes. There is uniform swelling of the joint 
structures and ligamentous attachments from inflammatory 
changes. The synovial fluid may be increased, becoming 
turbid from flakes of fibrin and leukocytes. Pus and blood in 
the joints are exceedingly rare. 

The blood shows important changes. In perhaps no other 
infectious disease, with the exception of diphtheria, pyemia, 
and septicemia, is the anemia so marked and so early produced. 
The red blood-cells may be reduced one-half or more in 
number, the hemoglobin reduced to 50%, and leukocytosis is 
common. The serous membranes of the heart are involved 
in about one-third of the cases, the left side being most often 
affected. Ulceration of the valve structure is rare. Myocar- 
ditis is not uncommon. 

Period of Incubation. — The period of incubation is un- 
known. 

Symptoms. — The disease begins suddenly, with fever rising 
to 102 or 103 ° F., with pain, tenderness, swelling, and red- 
ness in one or more of the joints. Most often the large joints 



24O INFECTIOUS DISEASES. 

are affected. Occasionally, prodromes are present. They 
consist of headache, lassitude, coated tongue, anorexia, con- 
stipation, and chilliness, with mild tonsillitis, pharyngitis, or 
laryngitis. Epistaxis may be present. These prodromes may 
precede the sudden onset by two or three days. The joint in- 
volvement is quite characteristic in the fact that the inflamma- 
tion shows a tendency to involve the joints symmetrically : 
that is to say, if the left knee is affected, the next joint likely 
to become involved is the right knee, etc. These joints are 
exceedingly painful, tender to the touch, red, and swollen. 

The pulse is accelerated from 1 00 to 105 a minute, soft and 
compressible. The temperature varies between 102 F. and 
104 F. It shows no characteristic type, and rises with the 
occurrence of complications. Hyperpyrexia occasionally takes 
place, with marked symptoms of headache and delirium, which 
later may be violent in character and end in coma. This has 
been called "cerebral rheumatism" and is extremely fatal. 
The urine is highly colored, of high specific gravity, — 1025 to 
to 1040, — scanty in amount, contains an abundance of phos- 
phates or urates and occasionally slight amounts of albumin 
(toxic). The saliva is strongly acid. Nervous symptoms, as 
a rule, do not appear, as the mind is clear throughout, except 
when hyperpyrexia occurs, with symptoms that have already 
been described. Copious acid sweats are characteristic of this 
disease. 

Urticaria and petechiae occasionally occur, as do ery- 
thema nodosum or erythema multiforme. Nodules varying 
in size from a pinhead to y^ of an inch in diameter appear ; 
these may be extremely numerous, painful, and tender, occur- 
ring in children particularly, and lasting several weeks and 
then disappearing. 

Follicular tonsillitis has been so frequently observed that by 
many a causative relation is supposed to exist between these 
two affections. 

One attack does not confer immunity, but, on the contrary, 
rather predisposes to other attacks. 

Complications. — Endocarditis and pericarditis occur in 
about one-third of the cases. By many these are considered 
as symptoms, and are not classed as complications. Pleurisy 
also is not infrequent, as is involvement of other serous mem- 
branes. Tonsillitis, bronchitis, bronchopneumonia, and chorea 
are noted as complications. 

Diagnosis. — This depends upon the abrupt onset, often with 



ACUTE RHEUMATIC FEVER. 2/j.I 

a preceding tonsillitis or pharyngitis, with an inflammation of a 
number of joints, usually the large joints, with fever, profuse 
sweating, and a marked tendency to implications of the serous 
membranes. 

Differential Diagnosis. — Differential diagnosis must often 
be made between rheumatic fever and pyemia, and this is usually 
a difficult matter, particularly if they occur in the lying-in 
woman. In rheumatic fever a very important point is that the 
joint affection is usually of a fugitive character, coming and 
going with great rapidity, whereas in pyemia the joint involved 
is apt to persist throughout the process. Pus is present in the 
affected joint in pyemia ; this is extremely rare in acute rheu- 
matic fever. 

Differential diagnosis between gout and rheumatic fever may 
be made from the fact that gout usually comes on very sud- 
denly, and shows a special preference for the smaller joints, 
most usually the great toe. The appearance of the joint is 
swollen and glossy, tense and bluish. In gout there is less 
sweating and less fever ; gastric and nervous symptoms are 
more likely to be present. 

Course and Duration. — Prognosis. — As a rule, this is a 
benign disease, terminating in recovery. It may, however, 
result fatally, from the intensity of the febrile process or from 
endocarditis or general hemorrhagic tendencies. In mild cases 
the process may come to an end in about a week ; in others 
the disease may last for months. The severity of the disease 
usually corresponds to the number of joints affected, but bears 
no relation to the cardiac complications, as severe endocarditis 
may result from but a slight joint implication. Recovery takes 
place even from cardiac complications, but complete recovery 
is rare, the acute forms of cardiac disease usually passing into 
the chronic variety. Cerebral rheumatism is almost invariably 
fatal. 

Treatment. — Rheumatic fever is fortunately one of those 
diseases for which it may be almost claimed that we possess a 
specific in salicylic acid and the salicylates. These drugs 
should be given in sufficient quantity to produce their physi- 
ologic effect. The drugs usually selected are either salicylic 
acid — which should never be given in form of a powder, but 
in capsules — or preferably the salicylate of sodium. An effort 
should be made to produce the physiologic effect of the drug 
in from thirty-six to forty-eight hours. Under treatment of 
this kind swelling subsides, redness disappears, and the tem- 
16 



242 INFECTIOUS DISEASES. 

perature falls rapidly. The treatment should be continued for 
some time after the symptoms of the disease have entirely 
ceased. If heart affections occur, especially early, it may be 
good practice to give some of the alkalies or an alkaline and 
salicylate treatment from the onset. This must be continued 
until the urine becomes distinctly alkaline in reaction. If the 
suffering of the patient is great, some form of opium should 
be administered. 

A light, easily digested diet should be used. Light farina- 
ceous foods, rice puddings, broth, and custards are preferable, 
but concentrated beef-broths and acid fruits should be pro- 
hibited. 

In convalescence some attention should be given to the high 
grade of anemia that almost invariably follows acute attacks. 
The local treatment for the joints should consist in their being 
wrapped in carded wool. Hot applications with ichthyol to 
the joints are useful. 

Rest is of great importance even in the mildest cases, as fre- 
quently the cases that show least joint affection may be the 
ones to show serious cardiac affection. The rheumatic hyper- 
pyrexia must be treated by ice to the head, or a tepid bath 
gradually cooled. Bold stimulation is necessary in a condition 
of this kind. 

Treatment of the Cardiac Complications. — When cardiac 
complications develop, the general idea is to change from the 
salicylates to the alkalies, such as sodium bicarbonate, potassium 
citrate, or potassium acetate, or some combination of these. 

Large blisters over the heart are of no use, as they add to 
the suffering of the patient and prevent systematic examina- 
tions. Small blisters at some distance from the heart, on the 
other hand, are often beneficial. Rest should be absolute for 
at least two or three weeks after the joint affection has sub- 
sided, as the heart beats eight to ten times less per minute in 
the recumbent posture, and this induces necessary heart-rest. 
Digitalis should be used only for special indications. 

DIPHTHERIA* 

Definition. — Diphtheria is an acute specific contagious dis- 
ease, due to the Klebs-Loffler bacillus, characterized by the 
formation of a false membrane, principally upon the mucous sur- 
faces and occasionally upon the skin, with fever and marked 
constitutional symptoms. The disease is not self-protective. 



DIPHTHERIA. 243 

Synonyms. — Putrid sore throat ; membranous croup. 

Etiology. — It is a disease of all climates and seasons, 
occurring especially in densely populated centers, but when 
introduced into rural districts it prevails with great virulence. 
Social condition is without influence as a predisposing cause. 
Filthy surroundings and bad drainage are favorable soils for 
its development. 

Age is an important predisposing factor, it being particu- 
larly a disease of childhood ; no age, however, is exempt. 
The sexes are alike liable. All catarrhal conditions of the 
mucous membranes of the throat and nose predispose. One 
attack does not confer immunity. 

Exciting Cause. — The Klebs-Loffler bacillus is the excit- 
ing cause. (For description of germ, see p. 1 1 1.) 

Pathology. — The false membrane is usually confined to 
the pharynx, but may involve the inner surface of the cheeks, 
lips, skin, tonsils, pillars of the fauces, uvula, soft palate, pos- 
terior and anterior nares, Eustachian tube, and the middle 
ear. In rare instances the trachea, bronchi, esophagus, and 
stomach are covered with membrane. 

The amount of membrane varies from a small patch (fre- 
quently situated on the tonsil) to an extensive exudate, which 
may block up the pharynx, larynx, or nares. 

The pseudomembrane is of a dirty-gray color, the mucous 
surface surrounding it being red, swollen, and edematous. 
The membrane may be readily stripped off, and leaves a 
swollen injected surface beneath. 

Microscopically, the free surface of the exudate is covered 
with diphtheria bacilli, and perhaps groups of cocci or other 
bacteria. The membrane consists of fibrin, numerous small 
round cells, red blood-cells, and leukocytes, many of which 
are disintegrated. 

When the exudate has gained a firm hold, the epithelium 
will be found partially or completely absent, the mucosa being 
continuous with the false membrane. The submucosa is in- 
filtrated with round cells, leukocytes, and red blood-cells. 
The lymphatics and blood-vessels are greatly dilated. In the 
inflammatory areas diphtheria bacilli are found. The separa- 
tion of the membrane in many instances is due to the outpour- 
ing of secretion from the mucous glands. 

Pneumonia, endocarditis, acute nephritis, and neuritis may 
occur as complications. 

Period of Incubation. — From two to five days. 



244 INFECTIOUS DISEASES. 

Symptoms. — The onset of the disease is rather rapid than 
abrupt. The early symptoms are discomfort and weakness, 
with headache and general malaise. Moderate fever is usually 
present at the onset. Pain in swallowing is often the earliest 
symptom that draws attention to the case. This may not be 
pronounced, and in very young children is not complained of. 
It should, however, be the rule of the physician always to ex- 
amine the throat when he is called to see a child who is taken 
sick with slight constitutional disturbances. Redness of the 
soft palate, with more or less swelling of the tonsils, are com- 
mon. Upon one or both of them, upon the half arches of 
the palate, or, less frequently, upon the pharynx or hard pal- 
ate small spots that are grayish-white in appearance show 
themselves. These spots, which are the first signs of the false 
membrane, are somewhat thickened and raised above the level 
of the surrounding mucous membrane, which is deeply con- 
gested, especially around its borders. If an attempt be made 
to forcibly detach these points, a bleeding surface is left 
beneath, and the membranes quickly reform. 

The exudate shows a tendency to spread, and for the first 
few days this extension may be rapid and extensive, involving 
all the surfaces. The toxemia is proportionate to the extent 
of the exudate. In severe cases the entire throat may be 
covered in a few hours. The extension may be upward toward 
the nasopharynx and forward into the nasal chambers, into the 
Eustachian tubes, or more often downward into the larynx, 
through the glottis into the bronchial tubes. The involved 
area varies greatly. Usually, it is limited to one or both ton- 
sils, extending a little upon the corresponding half arches of 
the palate or the edge of the uvula. 

The most common position for the exudate is upon the 
tonsil, less commonly upon the side of the uvula of the affected 
tonsil. There is early noticeable swelling of the lymphatic 
glands at the angle of the jaw. If the tonsils are not involved 
and only the larynx implicated, the lymph-glands in this 
locality are not found enlarged. 

The constitutional symptoms become intensified as the exu- 
date spreads. There is anorexia, thirst, deglutition is painful 
and difficult, and vomiting frequently takes place. The tongue 
is moist and coated with a thick yellowish fur. The fever is of 
irregular course, often rising to 104 F., though ordinarily it is 
of moderate intensity, and even in grave cases there may be low 
temperature, which is due to shock. The high temperature 



DIPHTHERIA. ' 245 

subsides in from three to four days. A continued high fever 
must be ascribed to some complication. 

The mind, as a rule, is clear, delirium and convulsions are 
rare. The pulse is rapid and weak. In mild cases the con- 
stitutional symptom^ ameliorate in from eight to ten days, and 
the membrane disappears with moderate rapidity. Albumin- 
uria occurs early — : upon the second or third day. In grave 
cases the disease may terminate fatally with great rapidity. If 
the membrane extends into the nasopharynx and nasal cham- 
bers, the toxemia is intense, and the symptoms are not neces- 
sarily due to faulty nasal respiration. The lymph-channels in 
the nasal chambers are extensive and relatively large, so that 
toxic material is readily and quickly absorbed. 

In nasal diphtheria there may be a mucopurulent discharge 
streaked with blood at the nose, and epistaxis is common. 

Laryngeal Diphtheria. — Diphtheria of- the larynx begins 
with symptoms of laryngitis. There is mechanical interfer- 
ence with respiration, and marked signs of suffocation may 
take place. 

The larynx in rare instances may be affected primarily, the 
disease spreading to the pharynx later. In other cases the 
larynx may be affected alone, but it is more usual for the 
membrane to spread from the pharynx to the larynx. 

The symptoms of laryngeal diphtheria are hoarseness, 
croupy cough, labored and difficult respiration, pallor of the 
face with cyanosis, and paralysis of the laryngeal muscles. 
Drowsiness sets in, and the patient may die in a comatose 
condition. Occasionally, in coughing the false membrane is 
dislodged, and recovery may take place if the membrane does 
not reform. This is, however, a rare occurrence. Tubular 
casts of the smaller bronchi may be coughed up. From ex- 
tension the membrane may reach the bronchi and alveoli of 
the lung, and produce bronchopneumonia. It may be due to 
this bronchopneumonia that relief in some cases of laryngeal 
diphtheria does not follow tracheotomy. The toxemia alone 
is capable of producing a fatal issue. In such cases the 
pulse becomes weak and rapid, and cardiac asthenia will be 
pronounced. This may occur without stenosis of the larynx. 

Septicemia from mixed infection may take place. Heart 
failure may develop, and prove rapidly fatal. This may 
occur during convalescence. Often between the second and 
third day the urine contains albumin, casts, and traces of 
blood. Edema, when present, is usually slight. 



246 INFECTIOUS DISEASES. 

Paralysis. — Diphtheric paralysis may show itself during 
convalescence, occurring in mild as well as severe cases. 
The soft palate is most frequently implicated. Swallowing 
is interfered with, and fluids regurgitate through the nose 
in consequence of the inability of the palate to approximate 
itself to the posterior wall of the pharynx, so that the pharyn- 
geal muscles contract on the substance or some portion of 
it and force it up into the nostrils. This is a form of 
motor paralysis. There may also be sensory paralysis. 
Paralysis of the muscles of the eye occurs ; strabismus is 
common, but paralyses of the trunk and of the extremities 
are less common. When this condition affects the mechan- 
ism of the heart, sudden death from paralysis takes place. 
The vocal cords may also be affected. The knee-jerks are 
often abolished. 

Diagnosis. — The direct diagnosis is easy. The exudate 
with the inflamed areola, severe local and constitutional 
symptoms are quite characteristic. If the tonsils alone are 
affected, some difficulty in diagnosis may occur. 

Follicular or lacunar tonsillitis often -simulates this condi- 
tion, and a bacteriologic test may be necessary. Pseudo- 
diphtheria frequently takes place in scarlet fever, and resem- 
bles true diphtheria, and here a bacteriologic examination is 
necessary to determine the true nature of the affection. 

Prognosis. — The death-rate varies in different epidemics, 
but the prognosis should always be guarded. Favorable 
conditions are : a limited membrane, slight swelling of the lym- 
phatic glands, and moderate fever. Unfavorable conditions 
are : marked local inflammation, thick false membrane, great 
inflammation of the lymphatics, and tendency of the membrane 
to extend upward or downward. The extension into the larynx 
renders the prognosis unfavorable, as is also the case in nasal 
diphtheria. 

Treatment. — Prophylaxis. — Prophylaxis is of the utmost 
importance, the disease being highly contagious and easily 
transmitted. The patient should be strictly isolated, although 
the area of contagion is limited. Efficient disinfection is 
necessary in the sick-room, and at the end of the attack the 
apartment should be thoroughly disinfected, as should also 
the bedding, clothing, etc. 

The sick-room should have a temperature of between 70 ° 
and 75° F. The food must be nutritious and easily digested ; 
milk, animal broths, and predigested foods are useful. If the 



DIPHTHERIA. 247 

patient swallows with difficulty or there is much vomiting, 
rectal alimentation should be practised. Alcohol is necessary, 
and must be given freely even in mild cases ; however, its in- 
fluence upon the pulse, heart, and nervous system should be 
carefully watched. 

The membrane must not be removed. Antiseptic and sooth- 
ing applications are employed ; inhalations of quicklime and 
steam in all cases in which there is danger of invasion into 
the larynx are useful. Hydrogen dioxid in solution is ser- 
viceable as a mouth- wash ; likewise, Loffler's toluol solution : 

& . Menthol 10 grams. 

Toluol 36 c.c. 

Ferri-sesquichlorid 4 c.c. 

Alcohol , 60 c.c. M. 

When symptoms of suffocation appear, the patient is placed 
in a warm bath with cold applications to the head. 

Internally, the tincture of chlorid of iron may be given in 
medium doses. Preparations of mercury, calomel, or corro- 
sive sublimate are beneficial. At the beginning of the 
attack a laxative dose of calomel is desirable ; following this, 
one-sixth to one-quarter of a grain may be given every 
two or three hours until free action from the bowels is pro- 
duced. 

The paralysis of diphtheria should be treated with iron, 
nux vomica, strychnia, and electricity. Rest and a nutritious 
diet are necessary, and the patient may be benefited by mas- 
sage. Heart failure and cardiac asthenia require absolute 
rest and the administration of alcohol ; strychnia also is of 
use in this condition. 

The expectant plan of treatment should not be adhered to 
in a disease like diphtheria. The case must be treated with 
energy and promptness, and an attempt made to control each 
symptom as it arises. 

Antitoxin Treatment. — The neglect to use the antitoxin 
treatment in the present state of medical knowledge should be 
considered almost criminal negligence. The earlier the treat- 
ment is instituted, the better the result. The dose in indi- 
vidual cases varies : in severe cases that have lasted some 
hours or a day or two the injection should be repeated, and 
from 1500 to 2000 antitoxin units used. From three to four 
injections may be required. Through this treatment the mor- 
tality has been reduced from about 50 per cent, to 20 per 
cent., or even lower. It should be practised even in sus- 



248 INFECTIOUS DISEASES. 

pected cases, and before the bacteriologic examination has 
been made. In laryngeal diphtheria it may be necessary to 
resort to intubation or tracheotomy. 

Arititoxin Injections. — The skin at the point of selection for 
the introduction of the serum should be treated as if for a 
surgical operation, and the syringe, which should have a 
capacity of from two and one-half to three fluid drams, steril- 
ized. The injection should not be beneath the deep fascia, 
but in the subcutaneous tissues, preferably in the back between 
the shoulder blades, or in the outer surface of the thighs, thus 
preventing the patient from seeing the operation. 

The serum should be slowly forced in, the needle withdrawn, 
and the puncture sealed up with rubber adhesive plaster or 
cotton and collodion, to prevent the fluid from escaping. The 
part should not be rubbed. The dose for immunization, which 
should always be used when there are small children in the 
household, is from 200 to 500 antitoxin units, or from 500 to 
1000, according to the age of the patient. There is no serious 
reaction and no danger from the serum itself if pure, there- 
fore full doses may be given. 

CEREBROSPINAL FEVER. 

Definition. — A malignant continued fever due to the diplo- 
coccus intracellularis, occurring in epidemics and occasion- 
ally as a sporadic disease, with marked symptoms relating to 
the cerebrospinal system, and constant anatomic lesions after 
death. 

Synonyms. — Epidemic cerebrospinal meningitis ; epidemic 
meningitis ; cerebrospinal typhus; petechial fever; spotted fever. 

Description. — This disease was first recognized as a sub- 
stantive affection about 1805. The earliest epidemics occurred 
in Switzerland and Southern France. The disease appeared 
in epidemic form in 1863 in the United States, and prevailed 
annually until about 1870. In 1873 the disease again became 
epidemic in this vicinity, since which time cases have con- 
stantly occurred, sometimes epidemically, occasionally in 
sporadic form. It is also an epizootic disease, as some of the 
domestic animals suffer from it, especially the horse. 

Epidemics usually run their course in from a few weeks to 
a few months. They have, however, prevailed for a year or 
more. The causes of the prevalence of epidemics are not 
known. 



CEREBROSPINAL FEVER. 249 

Etiology. — Predisposing Cause. — Climate is of no import- 
ance, the affection having occurred equally in warm and cold 
climates. Season is of some importance, as the majority 
of the outbreaks have occurred in the spring. Nothing is 
known in reference to temperature, moisture, or the direction 
of the wind. Altitude and soil are without influence. Damp, 
cold, and unclean residing places seem to predispose. Race 
and social condition are without influence. Among adults a 
larger proportion of females than males appears to suffer. No 
period of life, however, is exempt. 

Exciting Cause. — The diplococcus intracellularis meningi- 
tidis, described by Weichselbaum in 1887. (See p. 102.) 

Pathology. — Changes in the membrane of the cord and 
brain vary from an intense injection of the pia and arachnoid 
to a profuse fibrinopurulent exudate, the latter being the most 
common. 

An effusion of turbid serum into the subarachnoid space 
and ventricles is frequently met with. 

The exudation is commonly general, the membranes of the 
base of the brain, posterior portion of the cord, especially in 
the dorsal and lumbar regions, showing it to a greater 
degree. 

Inflammatory areas of the tissues of the brain and cord 
may be met with as a result of extensions. The spinal nerve- 
roots as well as some of the cranial nerves may be covered 
with the exudate. Microscopically, the exudate is largely 
composed of fibrin and leukocytes. The diplococcus is found 
in the exudate. 

The spleen is usually not enlarged. Pneumonia, pleurisy, 
and acute nephritis may accompany the disease. Leukocytosis 
is present. 

Period of Incubation. — This has not yet been definitely 
settled ; it is, however, estimated as being between three and 
five days. 

Symptoms. — The symptoms are related to two conditions 
— to the toxemia and to the local inflammation. Either of 
these two groups may predominate, and the symptoms vary 
accordingly. Prodromes are uncommon ; if present, they are 
not severe, and consist in malaise, slight headache, and stiff- 
ness of the limbs. The onset is sudden, beginning with in- 
tense headache, most frequently at the back of the head. 
Developing coincidently with this is stiffness in the muscles 
of the back and the neck. 



2 50 INFECTIOUS DISEASES. 

An initial chill may occur. There is fever with vomiting from 
the beginning. The vomiting is of the cerebral type. Delirium 
and stupor may be present early. The intensity of the early 
symptoms vary in different cases and different epidemics. 
Violent pains often occur with extreme rapidity, the symptoms 
appearing with lightning-like quickness. These cases are 
known as the "fulminant variety" in which the patient is 
overcome by intense toxemia. Nervous symptoms may appear, 
and the patient succumb in a few hours or days. On the other 
hand, they may be extremely mild, and the disease end in 
recovery in a day or two. This is known as the " abortive 
variety" Occasionally in epidemics, cases occur in which 
the symptoms are so mild and the toxemia so light that they 
would not be diagnosticated except for the knowledge of an 
epidemic. These are known as the " larval" or " undeveloped 
variety." Severe cases last from two to eight weeks, and 
may even then terminate fatally. 

Description of Symptoms. — The headache is usually occi- 
pital, although it may be general ; it is always severe. There 
may be periods of remission, being accompanied by a sense 
of fullness in the head with vertigo. There are pain in the 
neck, tenderness along the spine, and the muscles of the spine 
may contract so that well-developed opisthotonos is present. 
Delirium occurs early, and the disturbance of the mind may 
vary from slight drowsiness to profound stupor with wild, 
maniacal delirium. Convulsions take place in severe cases. 

Vomiting is a prominent symptom, and is of the cerebral 
variety, without much nausea and usually with a clean tongue. 

The symptoms referable to the individual nerves are varia- 
ble, the ones most commonly involved being those of the special 
senses. Ptosis may be present ; nystagmus, strabismus, dis- 
turbance of the pupils, and affections of the facial nerve may 
occur. Trismus may be a symptom. Tinnitus aurium is 
common. Optic neuritis occasionally shows itself with de- 
structive inflammation of the eyeball and purulent conjuncti- 
vitis or keratitis. The sense of smell may be entirely lost 
(anosmia). 

Disturbances of sensation are common, such as hyperes- 
thesia, anesthesia, and paresthesia. Subsultus tendinum is 
present, and the reflexes may be normal, exaggerated, or 
absent. The tendon reflex, however, is usually diminished or 
absent. The fever does not conform to a type, and its severity 
is not proportionate to the other symptoms. Hyperpyrexia 



CEREBROSPINAL FEVER. 25 I 

may occur or the temperature may not be higher than ioi c 
F. Herpes is characteristic and common in cerebrospinal 
fever, and may be of diagnostic value in doubtful cases. 
Other eruptions are sometimes present — erythema, urticaria, 
and petechias. Anorexia is present. Constipation is the rule, 
but diarrhea occasionally takes place. There is no appreci- 
able enlargement of the spleen. Arthritis is occasionally a 
symptom. 

The urine is scanty and has the characteristics of febrile 
urine. Albumin is present (toxic albuminuria). Polyuria and 
glycosuria occasionally occur. The respirations are increased 
in number, irregular, and shallow. 

Kernig's Sign. — Kernig observed a flexion contracture of 
the knee-joint, which in the sitting posture could not, without 
violence, be straightened beyond an angle of 135 degrees 
with the thigh, but which was readily straightened when the 
patient was in the erect or the recumbent posture. Kernig 
has examined several thousand persons especially for this 
phenomenon without finding it in a single instance except in 
cerebrospinal fever. 

Complications.— Bronchopneumonia, bronchitis ; endocar- 
ditis and pericarditis are rare. 

Sequels. — Sequels are exceedingly common. They con- 
sist in affections of the special senses. There may be loss of 
sight, permanent deafness, loss of smell, loss of taste, and 
various forms of paralysis. Gradual recovery may take place 
from some of these conditions, but this is unusual. 

Diagnosis. — In sporadic cases the diagnosis is difficult if 
the symptoms are not typical. The direct diagnosis rests upon 
the abrupt onset, grave cerebral symptoms, associated head- 
ache, vomiting, and painfid retractions of the muscles of the 
neck and herpes with the presence of Kernig' s sign. 

If the symptoms of meningitis be present in any case, it 
should be the duty of the physician to endeavor to ascertain 
whether it be a primary or secondary affection. It is secon- 
dary if it should occur from extension, from disease of the 
ear, the nose, or to traumatism, from some other infectious 
process, to brain abscess, and the like. Tuberculosis should 
always be suspected. 

Differential Diagnosis. — The differential diagnosis must 
be made between cerebrospinal fever and enteric fever. 

Enteric fever is more gradual in its onset, the cerebro- 
spinal symptoms occurring at the beginning of the disease. The 



252 INFECTIOUS DISEASES. 

fever has a typical curve. Dicrotic pulse is present. Vomit- 
ing is not frequent nor pronounced, and ceases early in the 
course of the disease. The eruption occurs at the end of the 
first week, and is characteristic. Abdominal symptoms are 
marked, and the spleen is enlarged early in the course of the 
disease. Delirium takes place late in the affection. Widal's 
reaction is important in doubtful cases. Photophobia is rare 
in enteric fever. 

Prognosis. — The prognosis is very grave, the average 
mortality being 45 f . The mortality is higher in the early 
course of an epidemic. Occasionally, epidemics occur in 
which all of the symptoms are slight, and very few deaths 
take place. On the other hand, some epidemics may show 
principally cases in which fulminant phenomena are promi- 
nent. 

Treatment. — Prophylaxis is unknown, and the treatment of 
the individual case is purely symptomatic. Cold applications 
to the head and to the spinal cord have received the sanction 
of the best practitioners. On the other hand, applications of 
heat to the head and spine may be found of use in some cases. 
A laxative dose of calomel is useful early in the course of the 
disease, and mercury throughout the entire affection has 
many advocates. Opium, perhaps, offers the best mode of 
treatment in this disease, and there is a remarkable tolerance 
for this drug even in the very young, as enormous doses may 
be given with benefit. It should be begun in small doses, 
which should gradually be increased until the effect of the drug 
is produced. Large doses of opium may be continued for a 
long period without danger to the patient. If vomiting is a 
prominent symptom, morphin should be given hypodermically 
instead of opium by the mouth. Chloral, the bromids, and 
cannabis indica have been used, but in effect can not be com- 
pared with the systematic use of opium. Alcohol should be 
given according to the requirements of individual cases. It is 
necessary when depression shows itself and asthenia is marked. 

CHOLERA, 

Definition. — A specific disease due to the comma bacillus 
of Koch, prevailing endemically in some parts of the world, 
occasionally becoming epidemic, characterized by vomiting, 
purging, muscular cramp, and a high mortality. 

Synonyms. — Cholera Asiatica ; cholera infectiosa. 



CHOLERA. 253 

Etiology. — The delta of the Ganges is the home of 
cholera. The disease first made its appearance in Europe in 
1830. It occurred in 1835 and 1836 in America for the 
first time, and from thence outbreaks have occasionally been 
noted. The disease is not restricted to any climate, epi- 
demics having occurred in Siberia and India. High tem- 
perature, however, favors the development of the disease and 
its spread, but cold weather does not necessarily arrest it. 
Cholera follows the line of travel, and affects particularly the 
centers of population, hence it is more likely to appear in sea- 
coast towns rather than inland cities. Individual immunity 
does not exist, all persons being susceptible to the disease. All 
ages are liable, children, however, suffering less in proportion 
than adults. Neither sex nor occupation have any influence. 
The mode of life of the individual, unhealthy surroundings, 
unclean habits of living, and insufficient food increase the 
danger of infection. Alcoholism, acute and chronic gastro- 
intestinal catarrh predispose. It is held by competent mod- 
ern observers that anxiety and fear act as predisposing causes. 

Exciting Cause. — The exciting cause is the comma bacillus 
of Koch, which gains access through the gastro-intestinal tract. 
(For description of the germ, see p. 116.) The germ multi- 
plies in the intestines, where toxins are thrown off, which are 
absorbed, and these produce the characteristic symptoms of the 
disease. 

Pathology. — The anatomic changes found in the cadaver 
are not characteristic. All the signs resulting from extreme 
collapse are present. There may be postmortem elevation of 
temperature. The rigor mortis is established early and is very 
intense, so that changes in the posture of the body may occur ; 
the position of the eyeballs may be changed, the closure of the 
jaw effected, and the posture of the limbs altered. 

The postmortem rigidity persists for some time. The body 
shows extreme emaciation from loss of fluids. The tissues are 
dry and doughy, and the outline of the bones may show 
through the subcutaneous tissues. The blood is dark in color 
and inspissated, the corpuscular elements are relatively in- 
creased. The fluid and salts of the body are diminished. The 
serous membranes are dry and lusterless. The internal 
organs show no constant changes. The mucous membrane 
of the intestines is swollen in many parts, denuded of epithe- 
lium, and the specific bacilli are found in its contents. The 
small intestine contains turbid fluid with epithelium and leu- 



2 54 INFECTIOUS DISEASES. 

kocytes. The spleen is usually small ; the liver and kidneys 
show parenchymatous degeneration. The heart is soft and 
friable, and the lungs are congested at the bases. 
Period of Incubation. — From two to five days. 

The Clinical Course of Cholera. 

Symptoms. — For the sake of convenience the attack of 
cholera may be divided into four stages : the stage of pre- 
monitory diarrhea, the stage of serous diarrhea, the stage of 
collapse, and the stage of reaction. 

Stage of Premonitory Diarrhea, — The patient has the symp- 
toms that are usual in an ordinary acute intestinal catarrh, 
with colicky pains, followed by large watery stools ; there 
may be from three to eight or ten in the course of twenty-four 
hours. 

There is anorexia, thirst, some headache, and depression 
with perhaps vomiting. There may even in this stage be 
symptoms of pain in the calves of the legs and diminished excre- 
tion of urine. Slight fever may be present. This stage may 
terminate in recovery in the course of two or three days, and 
is sometimes spoken of as "cholerine." 

Stage of Serous Diarrhea. — On the other hand, in the 
course of a few hours or a day or two grave symptoms arise. 
These usually come on at night, and the diarrhea continues, but 
is no longer fecal but serous. The stools are thin and copious. 
From absence of bile they lose their normal color and become 
grayish-white, flocculent in character, looking like rice-water ; 
hence the name, " rice-water stools." They are without odor 
and alkaline in reaction. Microscopically, they contain epi- 
thelial cells, crystals of triple phosphates, the comma bacillus, 
and other bacteria. The detection of the comma bacillus in 
this stage renders the diagnosis certain. Serous diarrhea is 
accompanied by vomiting, which is frequent but is unaccom- 
panied by much retching or distress. The vomited material 
consists of undigested food and sometimes of the rice-water 
discharge from reverse of peristalsis. The appetite is lost, 
thirst is extreme, and the tongue is thickly coated. 

This stage lasts from two to seven hours, and may terminate 
in reaction, but more frequently the patient merges into the 
stage of collapse. 

Stage of Collapse. — The effects of the toxins upon the ner- 
vous system are now manifest ; the diarrhea is less urgent, 
although the contents of the intestines may escape continu- 



CHOLERA. 255 

ously and involuntarily. The heart's action becomes more 
and more feeble. The pulse is almost imperceptible. The 
respirations are slow, irregular, and shallow. The surface 
temperature is subnormal, — 95 ° F. or less, — whereas the rectal 
temperature may show 103 F. to 105 ° F. The surface is 
cold ; the skin is inelastic, livid, and wrinkled, and shows 
evidence of profound collapse ; it is dry ; the fluids are not 
secreted. If urine is passed at all, it is of high specific 
gravity and contains albumin. Cramps in the muscles are 
prominent. There are convulsive movements of the legs, arms, 
hands, etc., which constantly recur. The mind, as a rule, 
remains clear. Great restlessness and excitement are excep- 
tional. This stage may last from a few hours to a day, and 
when death occurs in this stage, it is preceded by coma. 

Stage of Reaction. — This may succeed the stage of col- 
lapse. Instead of the case ending fatally, the evacuations 
become less frequent and copious, and cyanosis gradually 
disappears, the surface becoming warm. Vomiting ceases. 
Copious perspiration may occur. Secretion of urine in- 
creases, but this may contain albumin, casts, and blood-cor- 
puscles. If the progress of the case continue favorable, the 
urine becomes normal, the internal temperature falls, and the 
external temperature rises. 

This condition may be interrupted by a relapse, and the 
symptoms previously described may recur ; or the stage of 
reaction may, at the starting-point, develop a secondary infec- 
tive process. This is known as " cholera typhoid." 

Cholera Typhoid. — High temperature occurs, with head- 
ache, stupor, and delirium ; full, frequent, bounding pulse, with 
flushed face ; an eruption of an erythematous character may 
appear upon the chest or extremities. Symptoms of local 
inflammatory process may show themselves during the stage 
of reaction, such as a diphtheric enterocolitis with foul, purulent, 
bloody stools ; parotid bubo, which goes on to suppuration ; 
or diphtheria of the upper air-passages, with pneumonia and 
septicemia. 

Uremic symptoms may take the place of the two conditions 
just described, with all the symptoms of an ordinary acute 
nephritis : large amounts of albumin, free blood-cells, high 
specific gravity, vomiting, convulsions, and edema; marked 
dropsy is rare. These symptoms frequently terminate in 
death. Convalescence, however, may follow the stage of 
reaction, provided cholera typhoid does not occur. 



2^6 INFECTIOUS DISEASES. 

Occasionally, all these symptoms may be present without 
the marked serous stools. This condition is known as 
cholera sicca, in which the bowel is paralyzed ; hence, its fluid 
can not be voided. These are extremely fatal cases. 

The four following varieties of cholera have been described : 

Cholerine, or mild cases. 

Cholera fultninosa, a severe form with diarrhea and cramp, 
patient dying within a few hours with intense toxemia, not 
passing into the stage of collapse. 

Cholera sicca, due to paralysis of the gut. 

Cholera toxica, in which the patient is overwhelmed in the 
course of a few hours from the profound toxemia, and dies 
before the classic symptoms have manifested themselves. 

Diagnosis. — Direct diagnosis is not difficult in the face of 
an epidemic. In all doubtful cases bacteriologic examination 
is necessary. In times of epidemics every acute gastro- 
intestinal catarrh should be regarded as a possible case of 
cholera, and all necessary precautions taken. 

Differential Diagnosis. — Differential diagnosis between 
cholera nostras and cholera Asiatica may present difficulties, 
but a bacteriologic diagnosis will soon show the true nature 
of the affection. 

Prognosis. — Prognosis should always be guarded. Cases 
with mild premonitory symptoms may end fatally. The mor- 
tality in epidemics varies between 30^ and 80 fo> Especially 
unfavorable prognostic influences are alcoholism and the 
debility of previous disease. The extremes of age bear the 
disease badly ; in individual cases the prognosis is rendered 
unfavorable in proportion to the intensity of the collapse and 
the general toxemia. 

The death-rate is highest early in an epidemic. The prog- 
nosis is greatly modified by treatment. Cases that are 
promptly treated in the stage of premonitory diarrhea fre- 
quently recover. 

Treatment. — Prophylaxis. — Complete isolation of the 
sick, thorough disinfection of all discharges and all articles of 
clothing, etc., are absolutely necessary. The disease is not 
contagious, but the specific germ must gain access to the 
alimentary canal to effect infection. Efficient quarantine must 
be established. All water and milk should be boiled. No raw 
fruit or vegetables should be partaken of during the time of 
the epidemic. Every suspect should be promptly isolated, 
and all stools disinfected. 



THE PLAGUE. . 2$J 

Treatment of the Attack. — In the stage of premonitory 
diarrhea it is considered good practice to clear the bowels at 
the onset by a prompt laxative. After evacuating the bowel, 
small doses of calomel may be continued, one-sixth to one.- 
fourth of a grain every second hour. If there be pain and 
tendency to collapse, morphia should be administered hypo- 
dermically. Salol and guaiacol carbonate may be used from 
time to time as intestinal antiseptics. 

In the stage of serous diarrhea the patient should be 
wrapped in flannels, and external heat applied to the body. 
Friction of the muscles, if cramp occur, is useful. Fluids 
should be withheld except a few sips of iced champagne, or 
small lumps of ice given to allay thirst. The vomiting is often 
difficult to control ; a mustard plaster over the epigastrium or a 
few drops of chloroform are useful. If tendency to collapse 
is great, warm baths (from 103 ° to 105 ° F.) may be given. 
Whisky and brandy are often retained ;- if vomited, they 
should be given hypodermically. Enteroclysis should be 
practised in the stage of serous diarrhea. It may consist 
of boiled water at a temperature of 108 to 109 F., to 
which should be added five or ten drams of tannin, from 
thirty to fifty drops of laudanum, and some gum arabic ; 
two liters at a time should be slowly injected into the bowel. 
The enteroclysis may be repeated at an interval of two 
hours. 

In the stage of collapse the enteroclysis may be repeated, 
or hypodermoclysis of a normal salt solution may be re- 
sorted to. This does not exclude the practice of enteroclysis, 
which may be used conjointly. Lavage of a very weak acid 
solution, 1 part hydrochloric acid to from 3000 to 5000 
parts of sterilized water, is sometimes useful in allaying vom- 
iting. 

Strychnin hypodermically should not be repeated frequently, 
as the drug may accumulate in the tissues and produce toxic 
symptoms. Convalescence occupies several days, during 
which the diet must be carefully regulated. 

Cholera typhoid must be treated upon general principles. 



THE PLAGUE. 

Definition. — An acute, infectious, contagious disease, char- 
acterized by inflammation of the lymphatics, with a marked 
tendency to suppuration, and due to the bacillus pestis. 
17 



258 INFECTIOUS DISEASES. 

Synonyms. — Oriental plague ; bubonic plague ; pest ; the 
black death (of the fourteenth century). 

Etiology — Predisposing Causes. — -This is particularly a 
disease of poverty. Overcrowding, bad hygiene, filth, and 
insufficient food predispose in regions in which it occurs. It 
prevails in eveiy climate. Season of the year is without influ- 
ence. Fear, anxiety, and previous debilitating disease are said 
to be predisposing causes. 

Sex and age are without influence except after the fiftieth 
year, when it is an extremely rare affection. One attack does 
not confer immunity. 

Exciting Cause. — The exciting cause is the bacillus pestis. 
(For description of this germ, see p. 1 19.) 

Pathology. — The plague has prevailed in countries in which 
it has been extremely difficult to make postmortem study ; 
hence, little is known of the pathology. 

The spleen is enlarged, swelling, inflammation with a ten- 
dency to suppuration of the lymphatic glands, are the constant 
changes found after death. The inflammation is not always 
limited to the glands, but may extend to the contiguous tissues, 
in which extravasation of blood occurs. The inguinal glands 
are the ones most often involved, although enlargements may 
be found in the axilla, the neck, and other portions of the 
body. Petechiae, ecchymoses, and carbuncles are found upon 
the skin. The carbuncles often show large sloughs, which are 
surrounded by an inflammatory process. Parenchymatous 
degeneration of the heart, liver, and kidneys has been ob- 
served. 

Period of Incubation. — The period of incubation is from 
two to five days. 

Varieties. — Three varieties of the disease have been de- 
scribed : the grave, the fulminant, and the larval or abortive 
form. 

Stages. — The disease has been divided into the following 
stages for convenience of description : 

The stage of prodromes or invasion. 

The stage of the fully established disease. 

The stage of development of the buboes. 

The stage of convalescence. 

Symptoms. — Invasion. — The invasion is sudden, with las- 
situde, pain in the back and extremities ; the patient becomes 
dull and stupid, and acts like a person under the influence of 
alcohol or a narcotic. Fever may be slight or absent for a time. 



PERTUSSIS. 259 

Fully Established Disease. — The stage of the fully estab- 
lished disease is ushered in by a chill followed by high fever. 
The temperature may rise as high as 107 F. or 108 F. The 
patient becomes delirious, soon passing into stupor and coma. 
The circulation is rapid and feeble, and symptoms of collapse 
may occur. The lymphatics now begin to enlarge, and with a 
sudden fall in temperature, accompanied by copious sweating, 
the mind clears and the buboes in the groin, armpit, and angle 
of the jaw become prominent. In a large proportion of the 
cases the inguinal glands are the only ones affected. 

Development of Buboes. — The full development of the 
buboes marks the third stage. They vary in size from that of 
a pea to a small orange. As a rule, suppuration takes place, 
the gland breaking down on the third or fourth day after the 
formation of the bubo. In grave cases suppuration is absent 
altogether, carbuncles occurring in a considerable number of 
the cases. Petechias, which often appear early, show them- 
selves in the severer cases. 

Convalescence. — In the fourth stage convalescence, which 
may be greatly protracted by the local lesions, sets in some- 
where between the sixth and tenth days. Pus discharging 
from the lymphatics, carbuncles, and a prolonged relapse may 
lengthen the disease. Distinct second attacks occur. In the 
fulminant form death may take place in a few hours. 

Prognosis. — The mortality of the plague is greater than 
that from any other acute infectious disease. 

Diagnosis. — In the presence of an epidemic the diagnosis 
is not difficult. The direct diagnosis would depend upon the 
prodromes, the high fever with enlargement of the lymphatics, 
which suppurate, and the protracted convalescence. 

Treatment. — Cleanliness and strict observation of hygienic 
laws are necessary. Quarantine should be of the most ener- 
getic kind. The treatment is expectant-symptomatic. A 
purge at the onset is advantageous. Suppuration should be 
encouraged in the buboes, and these should be treated by 
antiseptic surgical methods. Bold stimulation is necessary in 
the severe cases. 



PERTUSSIS. 

Definition. — An acute, specific disease, occurring particu- 
larly in children, implicating the mucous membranes of 
the air-passages, characterized by paroxysmal cough. The 



26o INFECTIOUS, DISEASES. 

disease is highly contagious, and one attack confers im- 
munity. 

Synonyms. — Whooping-cough ; tussis convulsiva ; con- 
vulsive cough. 

Etiology. — A disease of early childhood, and common be- 
tween the periods of first and second dentition — that is, 
between the second and seventh years. It may occur in 
adults, but is then not well developed and the symptoms are 
not characteristic. 

Period of Incubation. — From seven to ten days. 

Exciting Cause. — By analogy it is supposed to be a spe- 
cific germ, which has not yet been isolated. Epidemics occur 
late in the spring and early in winter, and last from three to 
four months, often following or preceding outbreaks of 
measles or scarlet fever. 

Pathology. — There is no specific anatomical lesion. In 
unfavorable cases pulmonary complications, particularly bron- 
chopneumonia, are present. Pulmonary emphysema, with 
enlargement of the tracheal and bronchial glands, is found 
in some cases. 

Symptoms. — The disease is divided into two stages — 
the catarrhal and the convulsive stages. 

Catarrhal. — The catarrhal stage begins as an ordinary 
acute bronchitis, developing rapidly, with cough that is severe 
but not at all paroxysmal. Considerable loose phlegm is 
present at first, and large and small moist rales are heard in 
the chest throughout the course of the disease. -There may 
be sneezing, slight conjunctivitis, and a temperature between 
102° F. and 103 ° F., with furred tongue, loss of appetite, and 
constipation. This period lasts from seven to ten days, but is 
a variable one, and a diagnosis of pertussis can not be made 
in this stage. 

Convulsive Stage. — The symptoms continue, and to the 
catarrhal is added the convulsive stage. The cough is more 
violent, paroxysmal, and continuous, until a decided paroxysm 
takes place. It is a nervous cough, and is often more marked 
at night, occurring more frequently after taking food, causing 
the child to vomit. 

The paroxysm consists of a volley of coughing efforts that 
are expiratory in character with one or two short inspiratory 
acts between them. At the end of the volley of rapid ex- 
piratory efforts a long-drawn inspiration occurs with a crow- 
ing sound, due to fixation of the glottis but not an abso- 



PAROTITIS. 26l 

lute closure, and this long drawn inspiration produces the 
"whoop." 

During this period there may be cyanosis, swelling of the 
veins of the head, producing congestion of the face and neck. 
Hemorrhages may occur in the upper air-passages, from the 
throat, nose, tissues about the eyelids, with vomiting and in- 
voluntary evacuations. The number of paroxysms during 
the day vary ; there may be from five to ten in the course of 
twenty-four hours, or there may be as many as forty or fifty. 
An ulcer under the frenum of the tongue is very likely to 
occur in this stage, due to the projection of the tongue for- 
ward over the teeth in the paroxysm of coughing. 

Complications and Sequels. — Hemorrhages appear, such 
as petechias, about the face and neck. Epistaxis and hemop- 
tysis may occur, but they are of little importance. They 
usually terminate in recovery. Bronchopneumonia is a com- 
plication adding greatly to the gravity of the case, being the 
cause of the fatal issue in many instances. 

Pulmonary tuberculosis is comparatively frequent in a con- 
siderable proportion of the cases, especially in adolescence. 

Diagnosis. — This is impossible in the catarrhal stage, but. 
pertussis can not be confounded with any other disease in the 
convulsive stage. 

Prognosis. — As a rule, it is favorable, the danger being 
due to complications. The disease usually lasts from four to 
six weeks. 

Treatment. — Isolation is desirable, but is scarcely practi- 
cable. Food should be abundant and nutritious, and if the 
child vomits during a paroxysm, nourishment should imme- 
diately be readministered. Antipyrin in doses proportionate 
to the age of the patient has some influence on the paroxysms. 
Bromoform may be useful if it can be taken by the child, but 
it is very likely to give rise to nausea. Good hygiene is essen- 
tial in the treatment of the case. 



PAROTITIS, 

Definition. — An acute, infectious, contagious disease, 
characterized by swelling of one or both parotid glands, with 
trifling constitutional symptoms. 

Synonym. — Mumps. 

Etiology. — The exciting cause is an infectious principle, 
which has not yet been isolated. It is more frequent in the 



262 INFECTIOUS DISEASES. 

male than in the female sex. It is commonly encountered in 
childhood and early adult life, rarely in the extremes of age. 

Period of Incubation. — Period of incubation is about two 
weeks, it may be as long as three weeks. 

Symptoms. — Prodromes, if present, are slight, consisting 
of discomfort, headache, and some fever, with abrupt develop- 
ment of an enlarged parotid gland on one side. Inflammatory 
edema of the surrounding tissue may occur, so that the ear is 
pushed upward. The mouth is displaced, and the counten- 
ance disfigured. There is difficulty in chewing, swallowing, 
and eating. The temperature may reach 102 F., but is irreg- 
ular and not typical. The fever is often absent. In some 
cases the gland on the opposite side may become affected, but 
not until several days have elapsed or until inflammation in the 
other gland subsides. Abscess formation does not occur. 

The whole duration of the process is from eight to ten 
days, prolonged, however, by infection of the testicles when 
they become implicated, which is more likely to occur in 
adults than children. Other glands may be affected, such as 
the sublingual and the submaxillary. 

Diagnosis. — Diagnosis depends upon the sudden onset with 
enlargement in one of the large lymphatics about the neck, 
slight fever, and rapid subsidence. 

Prognosis. — Invariably favorable, all cases recovering. 

Treatment. — The patient should be isolated and a mild 
laxative given at the onset. Rest in bed is important. There 
is no specific treatment. Attention should be given to the 
prevention of complications and the alleviation of pain. 



INFECTIONS WITHOUT SPECIAL CLASSIFI- 
CATION. 

TUBERCULOSIS. 

Definition. — Tuberculosis is an infectious disease, caused 
by the tubercle bacillus of Koch, and characterized anatomi- 
cally by the formation of tubercles. 

Etiology. — Predisposing Cause. — This is a wide-spread 
disease, occurring in all parts of the universe, affecting both 
man and animals. About one-seventJi of all deaths are due to 
this disease. It is more frequent in the tropics than in tem- 
perate climates, and more frequent in cities than in the country. 



FEVER 



Diseases. 


Synonyms. 


Exciting 
Cause. 


Period of In- 
cubation. 


Pathology. 


Influenza. 


Epidemic catar- 
rhal lever ; la 
grippe. 


Bacillus of Pfeif- 
fer. 


From a few 
hours to two 
or three days. 


Catarrhal inflam- 
mation of muc- 
ousmembranes. 


En 
Ty 


teric fever. 


Typhoid fever ; ty- 
phus abdomin- 
al i s ; autumnal 
fever. 


Bacillus of 
Eberth. 


Two to three 
weeks. 


Lesions of Pey- 
er's patch and 
solitary folli- 
cles ; enlarge- 
ment of spleen. 


phus fever. 


Camp fever; jail 
fever ; ship fever. 


Not known. 


Variable, about 
two weeks. 


Granular and fat- 
ty degeneration 
of muscles and 
internal organs. 


Relapsing 
fever. 


Spirillum fever; 
famine fever ; ty- 
phus recurrens. 


Spirochaeta of 
Obermeier. 


Five to eight 
days. 


Enlargement of 
the spleen. 


Yellow fever. 


Yellow jack ; black 
vomit fever. 


Bacillus icte- 
roides. 


One to seven 
days. 


Fatty degenera- 
tion of the liver, 
kidney, and 
stomach, with 
hemorrhages. 


Dengue. 


Breakbone fever ; 
dandy fever; bro- 
ken wing fever. 


Not definitely de- 
termined. Mc- 
Laughlin's mi- 
crococcus. (?) 


Two to five 
days. 


Unknown. 


< 

s 

< < 

►J 

< 


Tertian fe- 
ver. 

Quartan 
fever. 

Estivo -au- 

tumnal 
fever. 


Chills and fever ; 
ague ; swamp fe- 
ver ; marsh fever; 
chagres fever; 
Roman fever. 


N * 

2 33 

X o 


Tertian 
parasite. 

Quartan 
parasite. 

Estivo - au- 
t um n al 
parasite. 


About ten days. 

About thirteen 
days. 

About three 
days. 


Enlargement of 
the spleen and 
liver, with pig- 
mentation. 


Scarlet fever. 


Scarlatina. 


Unknown. 


Four to seven 
days. 


Often parenchy- 
matous nephri- 
tis. 


Measles. 


Rubeola ; morbilli. 


Unknown. 


About ten days. 




Rubella. 


German measles ; 
French measles ; 
rotheln. 


Unknown. 


About eighteen 
days. 




Variola. 


Smallpox. 


Unknown. 


From ten to 
thirteen days. 




Varicella. 


Chickenpox. 


Unknown. 


Ten to fifteen 
days. 




Erysipelas. 


St. Anthony's fire ; 
the rose. 


Streptococcus 
v erysipelatis of 
Fehleisen. 


Three to seven 
days. 




Croupous pneu- 
monia. 


Lobar pneumonia ; 
fibrinous pneu- 
monia ; pneumo- 
nitis ; lung fever. 


Diplococcus lan- 
ceolatus; some- 
times other or- 
ganisms. 


Unknown. 


Engorge- •£ ^ § 
ment. * jv^ 

Consoli-1 &??S 
dation. 1 ~ §•£ 

Resolu-f-grg, 
tion. J pi S % 


Diphtheria. 


Putrid sore throat. 


Klebs-Loffler 
bacillus. 


Two to five 
days. 


Pseudomem- 
brane. 


Cerebrospinal 
fever. 


Epidemic cerebro- 
spinal meningi- 
tis; cerebrospinal 
typhus ; spotted 
fever. 


Diplococcus in- 
tra cellularis 
meningitidis. 


Three to five 
days ; (?) in- 
definite. 


Inflammation of 
the membranes 
of the brain and 
spinal cord. 


Acute rheu- 
matic fever. 


Acute inflamma- 
tory rheumatism. 


Unknown. 


Unknown. 




Cholera. 


Cholera Asiatica. 


Comma bacillus 
of Koch. 


Two to five 
days. 




Plague. 


Oriental plague ; 
bubonic plague ; 
pest. 


Bacillus pestis. 


Two to five 
days. 


Inflammation of 
the lymphatic 
glands. 


Pertussis. 


Whooping-cough, j Unknown. 


Seven to ten 
days. 




Parotitis. 


Mumps. Unknown. 


About two 
weeks. 





CHART 



Clinical Vari- 
eties. 


Eruption. 


Stages. 


Course. 


Termina- 
tion. 


Thoracic; gastro-intes 
tinal ; cardiac; ner 
vous. 






Few days to Crisis o r 
one week. lysis. 


Mild ; abortive ; ambu 
latory ; infantile re- 
mittent; grave; apy- 
rexial. 


About seventh 
i day. 




From twenty- ' Lysis, 
one to twenty- 
eight days. 




Fifth day. 




About fourteen , Crisis, 
days. 




Jaundice. 


Onset ; apyrexia ; ! About twenty- 
relapse, j one days. 
* 


Crisis. 




Jaundice. 


Onset ; calm ; col- 
lapse. 




Lysis. 




Urticaria ; ery- 
thema, etc., 
during stage 
of remission. 




Seven to eight 
days. 


Rapid 
lysis. 


Commonly intermittent 




Chill; fever; 
sweating. 


Variable. 


Commonly 
crisis. 


f Commonly remittent; 

irregular; continu- 
J ed; f algid, com- 
| and J atose, 

perni-j hemor- 
L cious. [ rhagic. 


Irregular. 




Latens ; simple ; angin- 
osa ; malignant. 


End of first or 
second day. 


Catarrhal ; erup- 
tion ; desquama- 
tion. 


Seven to ten 
days. 


Lysis. 


Simple ; malignant or 
hemorrhagic. 


Fourth day. 


Catarrhal; eruption; 
desquamation. 


Twelve days. 


Lysis. 




First day. 




Few days. 


Lysis. 


Discrete; confluent ; 
malignant ; varioloid. 


Third day. 


Invasion ; erup- Indefinite, 
tion ; secondary j 
fever. 


Lysis. 




First da>-. 




Abouttendays. 


Lysis. 




First day. 






Crisis com- 
monly. 




Herpes. 




Five to thir- 
teen days, 
more or less. 


Commonly 
crisis. 


Pharyngeal ; laryngeal; 
nasal. 






Indefinite. 


Lysis. 


Fulminant ; abortive ; 
larval ; common. 


Herpes and 
petechia;. 




Irregular. 


Lysis. 


Ordinary form ; cere- 
bral form. 






Four to six 
weeks. 


Lysis. 


Cholerine ; cholera ful- 
minosa; cholera sicca; 
cholera toxica. 




Premonitory diar- 
rhea ; serous di- 
arrhea; collapse; 
reaction. 


Short. 


Lysis. 


Grave ; fulminant ; lar- 
val. 


] 


D rodromal; fullyes- 
tablished disease; i 
development of 
the buboes ; con- 
valescence. 


Indefinite. 


Lysis. 






Catarrhal; convul- ; Four to six Lysis 
sive. weeks. 




Short. , Lysis. 



TUBERCULOSIS. 263 

Age, Race, and Sex. — All races and ages are susceptible, 
but the negro and Indian are particularly prone to this affec- 
tion. The Hebrew race possesses some degree of immunity. 
Of the two sexes, the female is probably more frequently 
affected. 

Occupation. — Certain occupations predispose, especially 
those that confine individuals to indoor life, depriving them of 
sunlight and necessary exercise, or exposing them to damp- 
ness. 

Infected dwellings predispose to the disease. It frequently 
reappears in certain localities in cities, and in houses in which 
tubercular subjects have died. 

Heredity. — Hereditary predisposition to the disease is 
marked, but the direct transmission of the specific cause does 
not occur. 

Individual Predisposition. — Individual predisposition con- 
sists largely in the shape of the chest. The long, narrow, 
flat chest, with depressed sternum is the form most frequently 
met with in tubercular patients. This may indicate nothing 
more than a delicacy of constitution with incomplete growth 
and imperfect development, but this form of chest, known as 
the " expiratory " form, is almost invariably met with in 
chronic tuberculosis. There must be some predisposition so 
that the germ may find a suitable soil for growth. 

Exciting Cause. — A bacillus discovered by Koch in 1882. 
This organism is found universally distributed in the dust, in 
soil, and in the various diseased tissues. It is found both in 
man and animals. (For description, see p. 104.) 

Modes of Infection. — Inoculation. — The inoculation of 
tubercular material directly through the skin produces tuber- 
culosis. This process is extremely rare in man, and is only 
met with in those who come in contact with the dead or with 
the products of dead animals. 

In such instances local tubercular processes are formed that 
may exist for years without showing the slightest tendency to 
spread. They should be classed with cases of lupus, of 
which they are practically a variety. 

Infection by Inhalation. — While it has been shown that 
the expired air of consumptives is not infective, the virus 
being contained in the sputum, the danger lies in the sputum 
becoming dried, mixed with dust, and inhaled by a suscep- 
tible person. In this way the disease is most frequently trans- 
mitted. 



264 INFECTIOUS DISEASES. 

Infection through the Gastrointestinal Tract. — Infection 
through the gastro-intestinal tract may occur as a result of 
drinking infected milk, this being derived from a tubercular 
udder, or by infected meat. Again, infection results from 
swallowing tubercular sputum, the latter being the most fre- 
quent cause Of intestinal tuberculosis. 

Pathology. — The naked-eye appearance of a tubercle is as 
follows : They are small nodules, varying in size from that of 
a millet to that of a mustard seed, and sometimes larger. They 
are multiple, distributed uniformly, or clustered, and show a 
tendency to fuse together, forming large masses. They are 
generally quite firm, gray in color, and when caseation takes 
place, the centers are more or less of a creamy yellow color. 
The tubercles are easily removed. by dissection. 

The pathology of the tubercle is the same in all organs. 

Microscopic appearance : After the bacillus lodges in an 
area, there is proliferation of the connective-tissue cells, which 
group around the irritant. Some polynuclear leukocytes 
wander into this area, but the latter feature is not marked. 
The accumulation of cells causes a nodule, which may be 
termed a " young tubercle." One or more of the connec- 
tive-tissue cells near the center of the mass may become en- 
larged, the nucleus proliferating and grouping around the 
periphery, called a "giant cell." The cells next to the giant 
cells seem to enlarge somewhat, and are called " epithelioid " 
cells, and the outermost layer of cells is called " lym- 
phoid " or round-cell area. The central part of the mass 
in almost every case undergoes cheesy necrosis, probably 
as a result of the cutting off of the circulation, and also the 
influence of the toxin. The cheesy mass, giant cells, epithe- 
lioid and small cells, arranged in the way just described, con- 
stitute a full-grown tubercle. These tubercles show a ten- 
dency to spread in all directions, more particularly in the route 
of the least resistance. Nature frequently shows a tendency 
to limit the spread by the formation of fibrous connective tis- 
sue around the tubercle, called a "healed tubercle." (Some 
of the connective-tissue cells of the outer layer form fibro- 
blasts, and finally fully formed fibrous connective tissue devel- 
ops.) Infiltration of lime salts into this capsule is common. 

It is stated by some pathologists that occasionally the 
giant cells that are nearest the center of the tubercle throw 
out fibrillated ends, and this process continues still further 
until fulfy formed fibrous tissue results. This explains the 



TUBERCULOSIS. 265 

entire cure in some instances. This view, however, is not 
accepted by most authorities. 

Secondary infection from a primary focus sometimes occurs. 
The tubercle breaks into a blood-vessel, the material being 
carried throughout the circulation, and lodges in various tis- 
sues, causing wide-spread or disseminated tuberculosis. In this 
condition the tubercles are rarely larger than a millet seed ; 
hence the name, general miliary tuberculosis. They are usu- 
ally uniformly of this size, and rarely show marked casea- 
tion. By many it is considered that a tuberculous lesion 
never causes suppuration, and that if the latter occurs it is 
as a result of secondary infection by some of the pyogenic 
micro-organisms. This condition is met with particularly in 
pulmonary lesions. 

Various tissues and organs are especially prone to the in- 
fection, as the lung and the lymphatic system. The spleen, 
kidneys, liver, intestines, and the brain are also very liable, but 
to a less extent than the tissues already indicated. The mus- 
cular and fibrous tissues are more or less exempt, but in rare 
instances may be affected. 

Amyloid disease sometimes results as a consequence of 
tuberculosis. Almost invariably fatty infiltration of the liver 
is associated with the chronic pulmonary forms. 

ACUTE MILIARY TUBERCULOSIS. 

Etiology. — As has already been indicated, when tubercle 
bacilli are distributed throughout the body by the blood stream, 
there is general infection, so that the picture may be one of 
acute infection. This is commonly the result of the breaking 
down of an old lesion, which may be in any part of the body, 
frequently in a lymphatic gland, in a pulmonary lesion, or in 
the bone-marrow. Rarely at the autopsy can this primary 
focus be found. It has been claimed that general miliary 
tuberculosis sometimes develops as a primary infection. 

The distribution of the tubercles in this variety is unequal, 
being abundant in some organs and scanty in others. 

Clinical Varieties. — i. The General or Typhoid Form. — 
In this variety the resemblance to an infectious disease is 
striking, and the course and general features may closely 
simulate enteric fever. Indeed, the resemblance may be so 
complete that days, and even weeks, may elapse before a 
positive diagnosis can be made — perhaps not until the 
autopsy. 



266 INFECTIOUS DISEASES. 

Symptoms. — The patient generally shows signs of failing 
health, with anorexia, accompanied by headache, chilly sensa- 
tions, slight cough, and digestive disturbances. These symp- 
toms may last for a week or two. Even epistaxis has been 
noted in such cases. Gradually the patient becomes feverish, 
with dry tongue, rapid pulse, respirations increased, and pul- 
monary symptoms becoming more marked. The pulse, how- 
ever, is rarely, if ever, dicrotic. The temperature does not show 
the steady increase so typical in the first period of enteric fever. 
The remissions are greater, and the entire fever-curve is more 
irregular. The fever may be intermittent, and in the early 
morning hours the temperature may be normal or subnormal. 
At times the inverse type of temperature is present. In rare 
cases pyrexia does not occur at all. Delirium is an early 
symptom, and is accompanied by restlessness, subsultus ten- 
dinum, and carphology. There is cutaneous hyperesthesia. 
Albuminuria is almost constant, and the urine often gives 
Ehrlich's diazo reaction. The gastric symptoms consist 
of vomiting, diarrhea, and even enterorrhagia, if tubercular 
ulcers exist in the bowel. The abdomen is tympanitic, and 
the spleen is enlarged. The disease may last from a few days 
to five or six weeks. The patient generally dies in coma, 
with Cheyne-Stokes respiration. The disease is invariably 
fatal. Tubercle bacilli have occasionally been found in the 
blood and in the dejecta. 

2. The Pulmonary Form. — In this variety the symptoms 
are very nearly the same as those already enumerated, with 
the exception that they are more closely related to the pul- 
monary system. There may be spitting of blood, although 
this is by no means the rule. The cough is more marked, 
the expectoration more profuse, and the respirations more 
rapid. Tubercle bacilli are rarely found in the sputum. When 
present, they are of diagnostic import. 

Physical Signs. — The physical signs may be those of a rapid 
breaking up of the pulmonary structure, with all the physical 
signs of bronchopneumonia. 

3. The Meningeal Form. — This variety is found most fre- 
quently in children, and by the older writers was called 
" dropsy of the brain." 

The distribution of tubercles in this variety is particularly 
in the membranes at the base of the brain and in the Sylvian 
fissure ; hence the symptoms closely simulate meningitis. The 
onset is variable ; it may begin abruptly, with intense cerebral 



TUBERCULOSIS. . 267 

excitement, or there may be symptoms of mania, and it may 
in a few days prove fatal. 

In a large proportion of cases, however, the disease runs a 
subacute course, and may be -prolonged over a period of 
months. 

The course of the disease has been divided into several 
stages, which are sometimes well defined : a prodromal stage, 
a period of excitement, and a period of paralysis. 

Prodromal Stage. — The disease may occur after one of 
the eruptive fevers, or may follow an injury such as a fall. 
The child becomes irritable and restless, especially at night ; 
there are loss of appetite and change in its disposition. 
Headache, tired feelings, pain in the limbs, accompanied often 
by obstinate vomiting, nausea, and constipation take place. 
The disease rarely begins with a convulsion. Fever is absent 
in the prodromal stage. 

Stage of Excitement. — The second stage is marked by an 
aggravation of the symptoms just enumerated, with the addi- 
tion of fever. The pain in the head becomes intense, the 
face is flushed, and the child utters a short, sudden cry known 
as the hydrocephalic cry. The headache may be frontal, 
though it is usually general, being aggravated by rays of 
light, noise, or any slight movement. The screaming may be 
continuous, only ceasing when the child is exhausted. Vom- 
iting is common, and may be independent of the taking of 
food ; it generally lasts but a short time, desisting in a few 
days ; occasionally, however, it remains throughout the entire 
course of the disease. Obstinate constipation is character- 
istic. The fever, from which the onset of this stage may be 
reckoned, is at first moderate, with evening exacerbations, 
being about 102° F., with rapid pulse, ranging from 120 to 
160 a minute. The abdomen is prominent, the tongue furred, 
and the breath offensive. 

Nervous symptoms are present, most often delirium. The 
pupils are contracted, and strabismus may be noted. There 
is marked cutaneous hyperesthesia, and the reflexes are exag- 
gerated. The " tache cerebrale " occurs, but is not diagnostic. 
Convulsive movements are common. There may be tonic 
spasm. If the spinal meninges are involved, there may be 
opisthotonos. This period persists for a week or ten days. 

Stage of Paralysis.— -In the final period, " the stage of 
paralysis," the fever becomes higher, often reaching 105 ° F. 
or 106 ° F. ; there may be hyperpyrexia, the temperature 



268 INFECTIOUS DISEASES. 

rising to no° F. ; spasmodic contractions are frequent, and 
there are tremor and twitching of the tendons and muscles, 
with local paralysis. In this form the ocular features are 
prominent. There may be conjugate deviation of the head 
and eyes. The third nerve is most frequently involved \ causing 
ptosis. Strabismus and optic neuritis are met with. Tuber- 
culosis of the choroid has been observed.- The duration of 
the disease is variable, the majority of cases lasting about 
three weeks, but when this form occurs in adults it may be 
prolonged to sixteen weeks or longer. The disease is almost 
invariably fatal. Leukocytosis has been found throughout the 
course of the disease. 

Differential Diagnosis. — Differential diagnosis must be 
made between miliary tuberculosis and enteric fever. 

Enteric Fever. Miliary Tuberculosis. 

Typical curve of the temperature. Temperature-curve atypical ; may be 

inverted type of temperature. 

Pulse not particularly rapid. Pulse always accelerated, especially in 

the meningeal form. 

Enlarged spleen early. Enlargement of the spleen occurs, but 

spleen can rarely be palpated. 

Eruption at end of first week, running Eruption rare and never typical, 
a typical course. 

Bronchitis occurs over the entire lung, Signs of bronchitis with particular in- 
more particularly marked at lower tensity at the apices of the lung 
than upper parts. showing early bronchopneumonia. 

Pericardial and pleural friction sounds Pericardial and pleural friction sounds 

rarely present. frequently present. 

Presence of the typhoid bacillus in ex- Tubercle bacilli in the sputum and in ex- 
creta ; sputum free from tubercle creta, although may rarely be found, 
bacilli. 

Diarrhea common ; stools may contain Constipation usually the rule. Tuber- 
typhoid bacillus. cle bacilli may be present in stools. 

Tongue characteristic. Dicrotic pulse Dicroticism rare ; tongue atypical, 
occurs. 

Meningitis extremely rare. Meningitis common. 

Widal reaction present. Widal reaction absent. 

TUBERCULOSIS OF THE LUNGS. 

Synonyms. — Phthisis ; consumption. 

Varieties. — Three varieties are described : Acute pneumonic 
phthisis, chronic ulcerative tuberculosis, fibroid phthisis. 

ACUTE PNEUMONIC PHTHISIS. 

The disease is apt to attack persons who have been weakened 
by previous illness, exposure, or dissipation. It may, however, 
occur in persons in perfectly good health. In nearly all in- 



TUBERCULOSIS. 269 

stances the disease is secondary to a preexisting tubercular 
focus, most often of the lung. 

Pathology. — Small tubercles are thickly distributed 
throughout both lungs, occasionally only confined to one, and 
rarely to a single lobe, and show slight tendency to the forma- 
tion of cavities. The lungs in this condition may weigh as 
much as 1600 grams. Occasionally, we find caseous broncho- 
pneumonia. 

Clinical Varieties. — Clinically, two varieties have been dif- 
ferentiated : (1) the pneumonic form and (2) the bronchopneu- 
monic form. 

Pneumonic Form. — The disease often begins abruptly, with 
chill, following exposure. The temperature rises suddenly, 
with all the initial symptoms of an ordinary croupous pneu- 
monia, and with cough and pain in the side. The expectora- 
tion may be blood-tinged and typically pneumonic, rusty 
sputum showing itself. In other cases the disease commences 
more gradually. One lobe may be found first affected, and 
the stage of consolidation come on with extreme rapidity ; the 
process spreads rapidly from lobe to lobe, so that soon the 
entire lung is involved. The fever is high and persistent, the 
pulse rapid — from 120 to 140 a minute. As the extension of 
consolidation proceeds, the respirations become accelerated, 
but even with all these physical conditions dyspnea and cyano- 
sis may be absent. 

About the ninth day of the disease, instead of crisis taking 
place, the fever persists and becomes irregular ; the expecto- 
ration is less rusty and becomes mucopurulent or of a green- 
ish color. Occasionally, expectoration may be absent alto- 
gether. 

Hemoptysis may occur at any time during the course of 
the disease. The spleen is enlarged, and there may be. edema 
of the lower extremities. Nervous symptoms are present, 
but are usually proportionate to the fever. The course of the 
disease is variable, death generally ensuing in about six weeks. 
' In some instances death takes place early, or the disease may 
not prove fatal for five or six months. 

Bronchopneumonic Form. — In this form persons in good 
health are rarely affected, and the disease presents a typical 
picture of galloping consumption. 

Hemoptysis sets in early ; loss of weight is rapid ; there are 
pronounced chills, sweats, and intermittent fever. The pulse 
is rapid, and the cough distressing. The apices of the lung 



27O INFECTIOUS DISEASES. 

are most frequently involved. The signs at first may be 
very slight ; subsequently, as the involved areas coalesce, 
bronchial breathing and dullness upon percussion are promi- 
nent. The disease may prove fatal in from six to twelve 
weeks ; the majority of cases of " galloping consumption " 
conform to this type. Occasionally, in the most desperate 
cases, when all hope has been abandoned, the symptoms ameli- 
orate and the disease becomes chronic. Tubercle bacilli may 
be present in the sputum. 

CHRONIC ULCERATIVE TUBERCULOSIS. 

Synonyms. — Phthisis ; pulmonary consumption ; chronic 
phthisis. This form embraces by far the largest number of 
cases of pulmonary tuberculosis. 

Pathology. — The lesions in this variety are variable. The 
most frequent seats of involvement are the apices of the lungs. 
The disease first begins as a catarrhal inflammation of the 
finer bronchial tubes and alveoli, the bacillus next setting up 
irritation in the interstitial substance of the lung. Tubercles 
are formed, and caseous degeneration appears. The nodules 
multiply,' the primary seat becoming densely infiltrated. The 
tubercles coalesce, and large cheesy deposits are formed ; as 
the large bronchial tubes become involved and the mass is dis- 
charged, cavity formation takes place. The blood-vessels 
show great resistance to the action of the poison, therefore 
vessels stretching across cavities as tense fibrous bands are 
sometimes found. In a paroxysm of coughing the vessels may 
be torn and copious hemorrhages result. Occasionally, slow in- 
volvement of the vessel-wall occurs. This is especially true of 
the smaller blood-channels. The pleurae are almost invariably 
involved, as are also the peribronchial glands. The pericardium 
may show tubercular lesions. There is frequently encapsulation 
of the tubercles, especially if there are lesions at the apices. 

Mixed infection is present in long-standing cases, causing 
suppuration and ulceration. The latter process may extend 
into the pleural sacs. If free communication between the 
bronchi and these cavities is established, pneumothorax may 
result. Fatty infiltration of the liver is almost constantly 
present, amyloid disease rarely. 

Symptoms. — No disease presents so varied a symptoma- 
tology at the onset as chronic pulmonary tuberculosis. The 
disease may begin in one of five ways : 

1. It may begin insidiously, with loss of strength and flesh, 



TUBERCULOSIS. 2J\ 

impairment of appetite, and slight evening rise in temperature. 
There may be some anemia and functional derangement of the 
digestive system. 

2. After repeated attacks of bronchitis, and in many cases 
after an attack of influenza. 

3. The symptoms may resemble an ordinary pleurisy. This 
may be of the dry form, or pleurisy with effusion, the other 
symptoms following the pleuritic attack. 

4. The onset is marked by profuse hemorrhage, the other 
symptoms following this condition. 

5. It begins as a laryngitis, with hoarseness and loss of 
voice, remaining so for some time before there is involvement 
of the lung. 

Cough. — The most important symptom is cough, which is 
dry and short, but accompanied sooner or later by expectora- 
tion. There is no relation between the severity of the cough 
and the gravity of the disease. When the larynx is involved, 
the cough is particularly hoarse and muffled, and may be 
paroxysmal in character : it may be so incessant as to produce 
vomiting. 

Expectoration. — At first the expectoration is scanty, but 
soon becomes mucopurulent and viscid ; it may be thin and 
watery from an admixture with saliva ; later in the disease it 
collects in thick lumps of a yellowish color — " nummular 
sputum." This is common where cavities are formed in the 
lung. In the advanced cases it becomes opaque, thick, and 
of a yellowish color. Blood is often found admixed with it. 
Fetor of the sputum is extremely uncommon, such changes 
being due to a mixed infection. It can not be said that any 
variety of sputum is pathognomonic of this disease. Only by 
the microscope can the diagnosis be made certain, when the 
presence of tubercle bacilli have been demonstrated in the 
sputum. 

Hemorrhages.— Hemoptysis is a prominent symptom of the 
disease, and may vary from a few drops to a pint or more ; 
this may prove directly fatal if the hemorrhage is very large. 
It is, however, more common for the patient to recover from 
the direct consequence of blood-spitting. Hemoptysis may 
be repeated frequently, and last from hours to days, with inter- 
missions. 

Dyspnea. — This is rarely complained of, except in the later 
stages of the disease. Increased frequency of respiration occurs 
early, upon slight exertion, being greater toward evening. 



272 INFECTIOUS DISEASES. 

Pain. — Pain in the chest is due to pleural involvement ; it 
may, however, be of muscular origin, due to the violence of 
the cough. 

Fever. — Fever, next to the cough, is the most important 
symptom ; it must be ascribed to the presence in the blood 
of a toxin produced by the bacillus or accompanying micro- 
organism. The fever is usually high toward afternoon and eve- 
ning. A slight evening rise may be one of the first symptoms. 
The onset of the disease may be marked by slight shivering, 
but a decided chill is present only, as a rule, in acute cases. 
The inverse type of temperature is sometimes present in this 
disease. Two main forms of fever may be distinguished : the 
intermittent and the remittent ; either may predominate, but 
usually there is a combination of both. The irregular course 
of the fever is diagnostic. Subnormal temperature not infre- 
quently occurs in the morning ; profuse night-sweats are a 
common symptom, and may have no relation to the intensity 
of the fever. 

Emaciation. — Emaciation is profound and proceeds from 
day to day; hence the names "phthisis" and "consump- 
tion." 

Anemia. — Anemia is marked, often of the chlorotic type, 
with no increase in the leukocytes, excepting when there is 
mixed infection. 

Pulse. — The pulse is rapid, but often small, being higher 
in the evening. 

Skin. — The skin of the tubercular patient is usually oily, 
and pityriasis is common ; the pigmentation may be so marked 
as to simulate Addison's disease. Cyanosis is rare ; coldness 
of the extremities is a common complaint. 

Lupus is occasionally found. The clubbing of the fingers 
and toes occurs in tuberculosis, being also found in other 
forms of disease in which failure of nutrition is prominent. 
The hair becomes thin and straight, but may remain quite 
thick and unusually profuse. On some persons a fine down 
is noticed all over the body. Edema of the feet is an almost 
constant symptom in the later stages of the disease. 

Gastrointestinal Symptoms. — Anorexia, vomiting, and 
nausea are symptoms from the onset, but are especially marked 
in the later stages. Diarrhea is a very serious symptom. It 
may occur early, but usually takes place later in the disease, 
and is associated with ulceration of the bowel. Tubercular 
disease of the stomach is rare. 



TUBERCULOSIS. 273 

Nervous Symptoms. — It has been known from the earliest 
writings that the peculiarity of the tubercular temperament 
consists in the marked hope of recovery. Patients with far- 
advanced disease frequently make plans for the future and con- 
fidently expect recovery. Other nervous symptoms are rare 
in chronic tuberculosis. 

Physical Diagnosis. — Inspection. — Great attention should 
be given to the shape of the chest, which in tubercular sub- 
jects is long and narrow. The intercostal spaces are wide, 
the ribs are more vertical in direction than normal, and the 
costal angle is very nearly acute. The chest is flattened in 
its anteroposterior diameter, the sternum is depressed, and the 
costal cartilages on one or both sides are prominent. The 
lower sternum may present a deep cavity, the so-called 
" funnel breast." The two sides of the chest maybe unsym- 
metric. In the early stages the clavicular regions show no 
marked changes, but if the disease in the apex has persisted 
for some time, changes are noted. 

The clavicle on the affected side is prominent, the supra- 
clavicular and infraclavicular spaces are distinct, and there is 
marked flattening, corresponding to the first, second, and 
third ribs of the affected side. In advanced cases the inter- 
costal spaces are much narrower, and the diseased side is con- 
siderably shrunken. The region corresponding to the heart 
may show a wide area of impulse. 

Defective expansion, especially of the apex of the lung, is an 
early and distinctive sign of tuberculosis. While most cases 
of tuberculosis show these changes, it must be borne in mind 
that advanced signs of tuberculosis may be present without 
any change in the contour of the chest. 

Palpation. — Palpation confirms inspection, and if disease of 
the apices be present, increased vocal fremitus will be noticed 
here as well as in other affected areas. At the bases a pleural 
exudate, which may complicate the disease, gives diminished 
or absent vocal fremitus. 

Percussion. — With deficient expansion at the apex there is 
usually some impairment of resonance ; this may show early. 
The note is higher in pitch than normal, and may be quite 
dull upon percussion if the disease is advanced. If cavities 
occur, the dullness gives place to hyperresonance, or even 
tympany. 

Auscultation. — Prolonged expiration is an early and valu- 
able sign. On the other hand, the first noticeable change 
18 



274 INFECTIOUS DISEASES. 

may be a harsh, rude, inspiratory murmur, the inspiration 
being jerky and of the so-called " cog-wheel " rhythm. If 
consolidation be marked, bronchovesicular and even tubular 
breathing may be present. Rales are heard, and may be due 
to an associated bronchitis, occurring only upon deep inspira- 
tion or during paroxysms of coughing. As the disease ad- 
vances, however, crepitant and subcrepitant rales appear. 
Pleuritic friction may exist at any stage, but is especially 
likely to occur when cavity formation takes place. The so- 
called " cardiorespiratory " murmur is often present ; it is best 
heard during inspiration and in the anterolateral regions of the 
chest. 

Signs of Cavity. — If the cavity exists at the apex, retrac- 
tion in the infraclavicular region becomes prominent ; this is 
combined with immobility of the affected side. The vocal 
fremitus is much increased, and the percussion sounds may be 
those of hyperresonance or tympany. The tympanitic qual- 
ity and the increased vocal fremitus disappear when the cavity 
is filled with fluid. Wintrich 's sign may be present — a distinct 
change of pitch when the mouth is opened or closed. Altera- 
tion in deep inspiration or deep expiration with a change in 
the position of the patient may occur. If the cavity be large, 
with thin walls, superficially situated, and connected with the 
bronchus, the "cracked-pot" sound is present upon percussion. 
On auscultation over a cavity great change in the breath- 
sounds takes place : they may be cavernous, tubular, or 
amphoric. In large cavities both inspiration and expiration 
may be typically amphoric. Over the area of a large cavity 
no breath-sounds may be heard. This may be due either to 
complete filling of the cavity with fluid or to the blocking of 
one of the bronchial tubes by a tough plug of mucus. The 
rales heard over the cavities are coarse, and may be bubbling 
in quality ; they are generally increased by deep inspiration 
or by coughing. 

The vocal fremitus is increased over a cavity if it be empty 
and superficially situated. Whispering pectoriloquy is pres- 
ent under these circumstances. If the cavity be near the 
heart, the sound of that organ may be heard, being directly 
transmitted. 

Complications. — The larynx may be the seat of extensive 
disease, with symptoms of huskiness of the voice, pain on 
swallowing, and wheezing cough. There may be aphonia. 
Ulcerative conditions may also be present. 



TUBERCULOSIS. 2J % 

Emphysema may be present in parts of the lung not 
affected by the tubercular process. Gangrene of the lung is 
rare. Pleurisy early accompanies chronic tubercular pro- 
cesses. It is most common in the apices, the signs of friction 
being prominent. Pleurisy with effusion usually precedes 
chronic pulmonary tuberculosis ; adhesions from pleurisy 
may occur at any part of the lung and become permanent. 
Pneumothorax is a common complication late in the disease, 
and rapidly proves fatal. 

Endocarditis is by no means so rare as was formerly sup- 
posed. Tuberculosis of the kidneys and bladder sometimes 
results during the course of the disease, giving the character- 
istic symptoms due to these conditions. 

Diagnosis. — In advanced cases the diagnosis may be made 
with ease. If puzzling symptoms appear, the detection of the 
bacillus will determine the diagnosis. 

FIBROID PHTHISIS. 

Pathology. — The lung showing fibroid phthisis reveals a 
small organ, greatly contracted and indurated, and on micro- 
scopic examination tubercles will be found, surrounded by 
fibrous connective tissue. In this condition the entire lung 
tissue may be replaced by tubercles with a great amount of 
fibrous connective tissue. It has been noted that one lung 
will show this condition while its fellow remains apparently 
normal, or compensatory hypertrophy will result. 

Symptoms and Physical Signs. — The symptoms of ordi- 
nary ulcerative tuberculosis may for a long time precede the 
development of the fibroid condition. The marked changes 
begin with the temperature, which, having been higher in the 
evening, now becomes normal ; sweating ceases, and the 
patient regains some degree of strength. Upon inspection it 
will be found that the affected side becomes more and more 
flattened, the intercostal spaces retract, and the respiratory 
movement diminishes. Impairment of resonance is noted 
on percussion, until complete dullness may be distinguished. 
With these signs there is displacement of organs, due to adhe- 
sions upon the affected side : the heart is pulled toward the 
diseased side, and the stomach may be drawn up. Emphy- 
sema of the opposite lung and hypertrophy of the heart de- 
velop. Bronchial breathing is marked, and pectoriloquy is 
often present. The respirations show little alteration, but the 
cough is paroxysmal and may be attended with profuse expec- 



2?6 INFECTIOUS DISEASES. 

toration. The urine often becomes albuminous. Hemoptysis 
is very much more marked in this form than in any other 
variety. 

The disease may remain stationary for years, but hemor- 
rhages are extremely likely to occur. The principal dangers 
in fibroid phthisis are : the hemorrhage, which is often pro- 
fuse ; the gradual extension of the disease ; and the failure of 
the circulation from cardiac influences. Dropsy, especially 
of the feet, takes place in the later stages of the disease. 

Diagnosis. — This is difficult. The history is of import- 
ance, as the disease frequently follows pleurisy, bronchopneu- 
monia, or chronic bronchitis. The absence of fever is an 
important diagnostic sign. The face is characteristic, present- 
ing the most marked features present in tubercular disease. 
The complexion is muddy, the hair is thick, and the eyelashes 
are long. The presence of tubercle bacilli is important in the 
diagnosis. 

Intercurrent Diseases. — The most important of these are 
lobar pneumonia, erysipelas, endocarditis, and anal fistula. 
The latter is quite common in pulmonary tuberculosis. 

TUBERCULOSIS OF THE LYMPH-GLANDS. 

Tubercular adenitis occurs at all ages, but is most frequent 
in children. It is common among the poor. The negro is 
especially susceptible. It is frequently associated with coryza, 
eczema of the scalp, and conjunctivitis. 

Pathology. — Tuberculosis of the lymphatic glands differs 
little in its pathology from the condition in other parts of the 
body, the most frequent seat being the submaxillary lym- 
phatic glands, usually unilateral ; if bilateral, the enlargement is 
greater on one side than upon the other. Other glands, such 
as the anterior and posterior cervical chains, the axillary, 
inguinal, mediastinal, and mesenteric, may be the seats of this 
affection. 

Suppuration results early, and the glands mat together. 
It is an undecided question as to whether the pus is the result 
of the tubercle bacillus, but it is generally supposed to be due 
to a mixed infection. 

Healing by encapsulation frequently results. In this event 
it is spoken of as being a drawn battle between nature and 
the disease. The focus for future infection may always be 
opened, and may give rise to general miliary tuberculosis or 
recurrence of the old condition. 



TUBERCULOSIS. 2JJ 

Clinical Forms. — The clinical forms may be classified under 
two headings : generalized tubercular lymphadenitis and local 
tubercular adenitis. 

Generalized Tubercular Lymphadenitis. — In generalized 
tubercular lymphadenitis the lymphatic system may be ex- 
clusively affected, and this is, perhaps, a more common type 
than is usually supposed. It is found in both children and 
adults. The symptoms are those of general cachexia, with 
little fever and without distinctive signs of involvement of the 
lung or abdominal organs. There may be irregular fever, 
and the patient may die without involvement of any of the 
viscera. These cases closely simulate Hodgkin's disease. 

Local Tubercular Adenitis. — This may affect the cervical, 
tracheobronchial, mesenteric, peritoneal, or other groups. It 
is usually considered to be a surgical affection, most common 
in young individuals, and not necessarily in those of a tuber- 
cular diathesis. 

The disease runs an extremely chronic course, and the 
glands are very likely to suppurate, surgical interference then 
being imperative. 

(For differential diagnosis between this disease and Hodg- 
kin's disease, which it sometimes closely resembles, especially 
in its onset, refer to Hodgkin's Disease, p. 625.) 

TUBERCULOSIS OF THE SEROUS MEMBRANES. 

Under this heading will be considered the pleura, the peri- 
toneum, and the pericardium. 

The Pleura. — The pleura, as has previously been men- 
tioned, may show the first sign of tubercular infection. If 
effusion follow, it may be serous, serohemorrhagic, or puru- 
lent ; of these conditions the serous effusion is the most 
frequent. It is conceded by bacteriologists that tubercular 
effusions are usually sterile, except when there is a mixed 
affection. 

The onset of the pleurisy may be insidious. Occasionally, 
the disease may come on acutely and run a subsequent chronic 
course. 

Symptoms. — The symptoms and signs in a tubercular 
effusion are those found with pleurisy resulting from other 
conditions, and are considered under that head. (See p. 

4I3-) 

Tuberculosis of the pleura may occur as a primary condi- 
tion, frequently as a secondary affection, from tuberculosis of 



278 INFECTIOUS DISEASES. 

the lung involving the visceral layer of the pleura or in the 
course of general miliary tuberculosis. 

Tuberculosis of the Pericardium.— This may be of either 
the acute miliary or the chronic form. It is met with -at all 
periods of life, and is most frequently found in the miliary 
variety. Effusions may be met with in the acute form, but are 
more commonly found in the chronic ; they may be serous, 
hemorrhagic, or purulent ; in the majority of cases they are 
serous. 

Symptoms. — The signs and symptoms are the same as 
those in pericardial effusion occurring under other conditions. 
The condition is rare. (See p. 316.) 

Tuberculosis of the Peritoneum. — The disease appears 
at all ages, but is more common in childhood. Males are 
more frequently attacked than females, and it is more often 
met with in the negro race than in the white race. It is 
also found associated with intestinal or mesenteric tubercu- 
losis. 

The condition may be primary in the peritoneum, and may 
be confined solely to this membrane. A common mode of 
infection is through the intestines ; this may also occur 
through the lymphatics or by extension from the pleura or 
the pericardium. It is often of the miliary variety, but also 
of the chronic ulcerative and chronic fibroid forms. 

Exudation is common, and may be serous, hemorrhagic, or 
purulent. The serous exudate is the most often encoun- 
tered. 

Symptoms. — The symptoms are those of peritoneal effu- 
sions in general. The onset is gradual, with or without 
fever. The patient soon becomes anemic. Nodules may 
be felt throughout the abdomen, these being the tubercles 
upon the peritoneum. It is commonly regarded as a surgical 
affection. (For symptoms of peritoneal effusion see p. 
510.) 

TUBERCULOSIS OF THE ALIMENTARY CANAL. 

This may affect the lips, but that is a rare situation. An 
ulcer may occur, and is more common in association with 
laryngeal and pulmonary disease. 

The diagnosis must often be made by inoculation experi- 
ments, or by finding the bacillus of tuberculosis in the ulcer 
or in tissues removed for microscopic examination. 



TUBERCULOSIS. 279 



TUBERCULOSIS OF THE TONGUE. 

This is nearly always associated with tuberculosis of other 
organs, and is most commonly at the dorsum, although the 
tip may be involved. It may occur from direct extension 
from the pharynx or epiglottis. 

Palate. — The palate is only involved from extension. 
The salivary glands apparently show a decided immunity 
against tubercular infection ; extremely few cases have been 
reported. 

The tonsil may be the seat of tuberculosis. Usually, how- 
ever, tubercular disease is found elsewhere in association, most 
commonly in the lungs. 

The pharynx and esophagus are likewise rarely involved, 
but usually from extension. 

TUBERCULOSIS OF THE STOMACH. 

Tuberculosis rarely affects the stomach, being either of the 
miliary or chronic caseous variety. The disease is secondary. 
The pyloric extremity and the greater curvature are usually 
involved. Perforation from a tuberculous ulcer has been re- 
corded. 

TUBERCULOSIS OF THE INTESTINES. 

This, with the exception of enteric fever, is the most fre- 
quent cause of intestinal ulceration. The large and small 
intestines may be affected, either in the course of the general 
miliary process, affecting usually the peritoneum in this condi- 
tion, or as a result of infection through the gastro-intestinal 
tract, resulting in the chronic ulcerative variety. The tuber- 
cular ulcer is the result of chronic caseous tuberculosis. Any 
part of the large or of the small intestine may be the seat of 
this condition, but usually the ileum is most prominently 
affected. The infection starting in Peyer's patch, anatomic 
tubercles are formed, and their spread is marked by a tendency 
to lateral distribution (in the short axis of the bowel). 

As caseation extends, rupture occurs into the lumen of the 
bowel and the ulcer is formed. Its characteristics are the fol- 
lowing : It is irregularly oval, the greater diameter of the ulcer 
being in the short axis of the bowel : the edges are over- 
hanging, and the peritoneal coat is thickened as a result of 
fibrous connective-tissue formation. Perforation is rare. The 



280 INFECTIOUS DISEASES. 

intestines, as a rule, do not show hyperemia around the affected 
area, but upon closer examination when the intestine is held 
toward the light, newly formed tubercles may be seen scat- 
tered throughout the intestines. 

Hemorrhage may occur from erosion of a vessel in the 
course of the development of the ulcer. 

TUBERCULOSIS OF THE LIVER AND PANCREAS. 

Tuberculosis also occurs in the liver and pancreas. In the 
liver it is usually of the miliary variety, the distribution of the 
tubercles being quite general. The tubercles are small, and 
often bile-stained. Chronic caseous tuberculosis of the liver 
is rare, and usually secondary to tuberculosis of the peritoneum. 

Tuberculosis of the pancreas is rare. 

TUBERCULOSIS OF THE GENITO-URINARY SYSTEM. 

Tuberculosis of the genito-urinary system is rare, and the 
process usually involves several parts of the tract. It maybe 
either miliary, or caseous — primary or secondary. It is com- 
monly considered a surgical affection. 

TUBERCULOSIS OF THE KIDNEY. 

The miliary form does not produce symptoms that are diag- 
nostic. In the caseous form the symptoms are extremely 
variable, but are usually those of pyelitis. The urine may be 
purulent, or contain flaky masses of caseous material for a 
considerable time, although the patient may have little or no 
distress. 

Polyuria may be present, with aching pains in the loins ; 
hemorrhages are not uncommon. The disease is frequently 
unilateral ; however, as it advances, both organs may be 
affected. 

Irregular fever, with loss in weight and strength accom- 
panied by rigors, is common. The urine presents changes 
common to pyelitis, pus-cells, blood, epithelium, and caseous 
masses being found. 

The tubercle bacillus is found in the urine. The smegma 
bacillus is frequently a source of error. (For mode of 
differentiation see p. 105.) 



TUBERCULOSIS. 28 1 

TUBERCULOSIS OF THE MAMMARY GLAND, 

Tuberculosis of the mammary gland is met with and is a 
surgical affection. 

TUBERCULOSIS OF THE BRAIN AND CORD. 

Tuberculosis of the brain of the miliary form has been de- 
scribed under acute miliary tuberculosis. The caseous variety 
is sometimes found, but is very rare. The symptoms are not 
diagnostic, other than the signs of a general localization of 
a tumor. When symptoms of this sort occur in children, 
with tubercular lesion elsewhere, this condition should be sus- 
pected. 

Tuberculosis of the spinal cord appears in the same forms 
as in the brain. 

TUBERCULOSIS OF THE ARTERIES AND HEART. 

Tuberculosis of the arteries and heart (endocardium and 
myocardium) rarely occurs. 

Diagnosis of Tuberculosis. — The diagnosis of tuberculosis 
depends upon the finding of the bacillus, or inoculation of 
tubercular material in animals, producing the disease, or injec- 
tion of tuberculin, producing reaction when the disease is 
present, as is now so frequently practised in veterinary medi- 
cine. The diagnosis is difficult when the bacillus is not found, 
especially so in the miliary variety. 

Prognosis. — Spontaneous recovery from local tuberculosis 
is not infrequently met with, and even tubercular disease 
of the bones, of the joints, and adenitis may heal without 
medication. Postmortem examination shows that a very large 
percentage of the bodies examined present tuberculous foci 
either in the lungs, the glands, or elsewhere, which have healed 
in. Cure sometimes takes place even in advanced cases of 
tuberculosis, as has been shown in cases in which all the symp- 
toms of a marked chronic tubercular process have been present, 
with bacilli in the sputum, which have afterward disappeared 
and the patient regained complete health. 

The following points are of favorable prognostic import in 
average cases. Previous good health, good family history, 
good digestion, and favorable environment. A slow onset 
without much fever and absence of great consolidation is also 
favorable in tuberculosis of the lung. 



282 INFECTIOUS DISEASES. 

The cases that begin with pleurisy run a very protracted 
course. Among the favorable symptoms, the absence of fever 
is the most important. The higher and more persistent the 
fever, the graver the prognosis. Repeated attacks of hemop- 
tysis are unfavorable, particularly if high fever is also present. 

Probably the gravest cases of the chronic pulmonary forms 
are those that begin with early gastric disturbance. In chronic 
cases the average duration of tuberculosis is about two years. 

Treatment. — Prophylaxis. — The most important measures 
of prophylaxis are absolute and total disinfection of the infected 
excreta, particularly the sputum. As has already been pointed 
out, when the sputum dries and is carried by dust particles, 
and again inhaled by a susceptible person, infection arises. 
The majority of infections occur in this way. Veterinary in- 
spection of milk and meat is of great importance. 

Individual Prophylaxis. — A tuberculous mother should not 
be allowed to suckle her infant. The convalescence of chil- 
dren from fevers, particularly measles and whooping-cough, 
must be carefully guarded. It is not well for a healthy person 
to sleep with one suffering from tuberculosis. 

Persons subject to tuberculosis should always endeavor to 
obtain outdoor occupation. 

Dietetic Treatment. — Blood-producing foods, which are 
easily digested, such as red meats, milk, eggs, fats, etc., are of 
especial use in the treatment of tuberculosis. It is important 
that the digestion be preserved and especial attention paid to 
it. The meals should not be large, but frequently repeated, 
so that the patient may receive food every few hours. Alco- 
hol is not necessary as a routine treatment. 

Climatic Treatment. — Climatic treatment is of great im- 
portance, an even, dry climate being more favorable. As a 
rule, high altitudes furnish this, but a cold climate is not suited 
to laryngeal and nervous cases, these doing better in warm 
climates. Unless the case be one of general miliary tubercu- 
losis, the patient should be sent away as soon as possible. 

General Medicinal Treatment. — The drugs that have been 
found generally useful and have received the sanction of the 
profession are those that have an influence over general nutri- 
tion, that increase the normal physiologic resistance, and render 
the tissues less liable to invasion. 

Such drugs as creasote and its derivatives, benzosol, tere- 
bene, guaiacol, arsenic, iodid of potassium, cod-liver oil, hypo- 
phosphites, and iron are the most valuable. 



SEPTICEMIA. 283 

Treatment of Special Symptoms. — Rest is the most im- 
portant factor in the treatment of fever, and the use of drugs 
is unsatisfactory. Sponging with tepid water is of use, and 
occasionally combinations of quinin, digitalis, and the salicy- 
lates give good results. The coal-tar antipyretics act with 
promptness in reducing the fever, but the debility is markedly 
increased by the use of these drugs. 

Night-sweats. — Atropin is the most valuable drug for the 
treatment of this condition. Camphoric acid and aromatic 
sulphuric acid are also sometimes found efficient. 

Cough. — Opium in some form is necessary to alleviate cough. 
Heroin in small doses is a useful agent. 

Diarrhea. — If symptoms of diarrhea occur, bismuth in large 
doses, combined with opium, will be found efficient. 

Treatment of Laryngeal Complications. — Local treatment 
directed to the healing of the ulcers is often found of use. 

Hemoptysis. — Absolute rest, withholding of food, ice-bags 
applied to the chest, and administration of opium are the 
most valuable methods for combating this symptom when it 
becomes serious. 

Treatment of Tuberculous Peritonitis — Laparotomy is fre- 
quently useful in this condition, and the case should come 
under the care of a surgeon. 



SEPTICEMIA, 

Definition. — Septicemia is a disease characterized by the 
presence of bacterial poisons and bacteria in the blood, and 
by marked constitutional symptoms without suppuration. 

Etiology. — The condition, as a rule, results from some local 
infective area, as general peritonitis, appendicitis, pneumonia, 
enteric fever, or gonorrhea. Various micro-organisms have 
been found in the blood, such as the staphylococcus, the ty- 
phoid bacillus, the streptococcus and others, the streptococcus 
being considered to give rise to the most severe symptoms. 

Occasionally, the condition arises without a local infection, 
and may then be called cryptogenic septicemia. 

Pathology. — The blood shows marked changes, both dur- 
ing life and after death. As a rule, a marked inflammatory 
leukocytosis exists. This may vary somewhat. If the infection 
be very intense or overwhelming, or if the individual resisting 
power is not marked, a leukocytosis may not be present, and 
occasionally a hypoleukocytosis may be found. If the resist- 



284 INFECTIOUS DISEASES. 

ing power of the individual is pronounced, or if the infecting 
agent is not severe, a decided leukocytosis results. As a 
consequence of the infection, the erythrocytes show a pro- 
nounced reduction, and the hemoglobin will also be propor- 
tionately reduced. It is said that the most marked oligocy- 
themia exists as a result of septicemia, showing that hemolysis 
is pronounced. After death the organs may show evidences 
of hyperemia and cloudy swelling ; otherwise nothing specific 
has been found. 

Symptoms. — The condition begins abruptly with chilliness 
or a decided chill, followed by fever, which rises and falls with 
slight remissions, however, remaining quite high — from 103 
F. to 105 ° F. The pulse is rapid, and gastro-intestinal dis- 
turbances are frequent. Anemia soon begins to be pro- 
nounced, and there may be slight jaundice. Purpuric symp- 
toms are not unusual in the course of this disease. 

Mental disturbances, manifested by delirium, are quite 
common, and melancholia not infrequently develops. The 
condition may terminate fatally within twenty-four hours or 
more, or the disease may run on for weeks and sometimes 
months. 

Less frequently, septicemia develops without a discoverable 
primary focus, attacking individuals in perfect health, and at 
the autopsy the primary focus can not be ascertained. 

The urine shows the characters common in febrile condi- 
tions, and often contains albumin (toxic) with numbers of 
bacteria. 

Diagnosis. — -The diagnosis is made with ease if a primary 
focus can be found. The type of fever, the pulse, and the 
examination of the blood revealing a leukocytosis and marked 
anemia usually determine the true nature of the affection; 
this condition may simulate malaria, but the detection of the 
Plasmodium is all that is necessary to differentiate between 
them. 

If possible, a bacteriologic examination of the blood should 
be made in order to determine the character of the micro- 
organism that may be present. 

Prognosis. — The prognosis is always to be regarded as 
serious. A marked leukocytosis will either show good re- 
sisting power or a severe infection. Streptococcus infection is 
regarded as more severe than other forms. 

Treatment. — Surgical treatment is, as a rule, necessary, 
especially when the primary focus exists as an abscess or 



PYEMIA. 285 

some other surgical condition. When the condition is purely 
medical, such as occurs in pneumonia, the focus should be 
treated. General constitutional measures must be employed : 
quinin, antipyrin, and antifebrin may control the temperature 
for a short time. The temperature may also be controlled by 
sponging. Strychnin and alcohol should be given as systemic 
tonics. Some cases show remarkable and brilliant results if 
antistreptococcic serum is used, when the affection is of this 
character of infection. 



PYEMIA. 

Definition. — Pyemia is a condition characterized by marked 
constitutional symptoms and multiple abscess formation in 
various parts of the body, and by changes in the blood — and 
necessarily in many other tissues — due to micro-organisms 
and their toxins present in the blood. 

Etiology. — As a rule, an original focus can easily be 
determined, such as have already been mentioned in septi- 
cemia, the condition being especially common in osteomye- 
litis, otitis media, empyema, appendicitis, and peritonitis. 

Pathology. — Multiple abscesses are found in pyemia, scat- 
tered widely through the entire organism. A frequent seat is 
found in the liver, but no part of the body is exempt. These 
abscesses result from septic emboli (produced by the breaking 
up of thrombi), these lodging in the smaller blood-vessels, 
causing septic infarcts. Abscess formation is the result of the 
septic emboli ; it is possible that the phagocytes of the blood 
are not able to deal with the micro-organisms as they exist 
in these particles, while in septicemia the micro-organisms 
exist as individual units, the phagocytes being able to exert 
their power, thereby preventing suppuration. As in septi- 
cemia, the blood shows changes, leukocytosis being marked 
and destruction of the red cells pronounced. 

Symptoms. — The onset is marked by chill and a rise in 
temperature, followed by sweating. There is loss of appetite, 
vomiting, and diarrhea. The chill, fever, and sweat usually 
occur with great regularity each day or every other day. 

As the abscess formation develops, symptoms make their 
appearance, depending upon the locality in which the abscess 
forms. Intense pain may be noticed in the region of the 
spleen or liver. Malignant endocarditis, pericarditis, or pleu- 
ritis may develop. Embolic abscesses in the brain substance 



286 INFECTIOUS DISEASES. 

will reveal definite symptoms, depending upon their location. 
Emaciation and anemia are marked as the disease progresses. 
The condition may last from a few days to two months. 

Diagnosis. — The direct diagnosis depends upon the original 
focus of infection, the characteristic fever-curve, and the symp- 
toms resulting from abscess formation. Leukocytosis should 
again be sought for. This condition is often confounded with 
malaria. The presence of the plasmodium in the blood easily 
differentiates the two conditions. 

Prognosis. — As a rule, the prognosis is unfavorable. 

Treatment. — Surgical treatment is usually necessary. The 
condition is treated as is septicemia. 

ANTHRAX. 

Definition. — An acute infectious disease, occurring as a 
result of accidental inoculation caused by the bacillus of an- 
thrax. The disease is common in animals, particularly sheep 
and cattle. 

Synonyms. — Malignant pustule ; charbon ; splenic fever or 
wool-sorter's disease. 

Etiology. — This is a wide-spread disease in animals. It is 
prevalent in Europe, Asia, Australia, and America. The dis- 
ease is conveyed to man as a result of the handling of wool 
or hides, rarely by direct inoculation from the bites of insects 
that have fed on animals that have died of the disease. It is 
very rare in man. 

Certain occupations predispose, such as stable-men, tanners, 
butchers, shepherds, and wool-sorters. 

The exciting cause is the bacillus of anthrax. (For de- 
scription of the germ see p. 108.) 

Pathology. — A malignant pustule exists, the favorite situa- 
tion being upon the neck, face, or arms. The lymphatics near 
this acute inflammatory area will show enlargement. The 
spleen is enlarged and softened. 

Symptoms. — The onset of the local infection is marked by 
itching and uneasiness. In a short time a papule, soon be- 
coming vesicular, develops. Swelling and redness of a dusky 
hue soon follow, and in about thirty-six hours marked inflam- 
matory induration exists, the neighboring lymphatic glands 
being swollen. As a rule, the temperature rises as the inflam- 
mation extends, but it may occasionally fall and become 
subnormal. 



ACTINOMYCOSIS. 287 

The constitutional symptoms depend upon the extent of 
the local inflammation, and resemble septicemia. As the local 
inflammatory area becomes more pronounced, suppuration 
ensues. An intestinal form, described as intestinal anthrax, is 
marked by symptoms of intestinal toxemia, vomiting, diarrhea, 
rapid pulse, and fever. Delirium may develop. 

Diagnosis. — The diagnosis, which is always difficult, de- 
pends upon the finding of the bacillus. 

Prognosis. — The prognosis is unfavorable. Death not in- 
frequently results within twenty-four hours. 

Treatment. — The pustule should be treated surgically, the 
site of inoculation being destroyed by bichlorid of mercury, 
carbolic acid, or the actual cautery. Constitutional treatment 
consists of the use of quinin, iron, strychnin, and alcohol. 

ACTINOMYCOSIS. 

Definition. — An infectious disease caused by the ray fun- 
gus, or streptothrix actinomyces. 

Synonyms. — Lumpy jaw ; wooden jaw. 

Etiology. — The disease is common in cattle and is rare in 
man. (For description of the parasite see p. 121.) 

Pathology. — The streptothrix actinomyces produces a 
granulation tumor not unlike that produced by the bacillus of 
tuberculosis. The small mass consists of proliferated connec- 
tive-tissue cells, most of them being small ; some larger epi- 
thelioid or giant cells may also be present. The most common 
seat of development is in the jaw, where it simulates osteo- 
sarcoma. Suppuration develops, and the ray fungus may be 
found in the pus. 

The mode of entrance of the germ in man is commonly 
supposed to be by the alimentary tract, the fungus being swal- 
lowed, or lodging in a decayed tooth, and thence by its growth 
setting up the symptoms of the condition. 

Symptoms. — The clinical course of the disease is usually 
chronic, the symptoms manifesting themselves slowly. Excep- 
tionally, the onset may be abrupt, due to the rapid growth of 
the fungus. If the disease occurs in the jaw, rapid swelling 
of the hard and soft tissues may ensue. 

The fungus may enter the larynx and gain access to a bron- 
chus, and the characteristic changes develop in the lung, or it 
may lodge in the intestine and the growth take place there. 

The symptoms may resemble an acute infectious disease or 



288 INFECTIOUS DISEASES. 

a pyemic process, but this is exceptional, for if pus-formation 
result, it may be ascribed to an accidental infection " or to the 
fungus " (Israel). 

When the disease occurs in the jaw, invasion of neighbor- 
ing tissues, accompanied by great swelling with the forma- 
tion of cicatricial tissue, occurs. Abscess formation soon 
takes place, and pus exudes, containing yellowish granules 
that, under the microscope, show the distinctive character of 
the growth. 

If the lesion be developed in a bronchus, bronchitis is set 
up, which may be putrid in nature, the expectoration contain- 
ing the fungus. Abscess formation may result in the lung and 
adjacent tissues. In the intestine the growth may occur with 
swellings in the lymph nodules, accompanied by diarrhea. 
There are also rapid emaciation and loss of strength. 

Diagnosis. — The chronic character of the disease, the swell- 
ings, the changes in the organs, with the appearance of the 
yellowish granules in the pus and the identification of the 
fungus under the microscope, render the diagnosis certain. 
Vegetable fibers in any discharge (especially pus) should be 
regarded as suspicious. 

Prognosis. — If the disease appear externally in bone or in 
the skin and remain local, a cure may occur ; in the viscera 
(lung, liver, brain, etc.) the prognosis is unfavorable. 

Treatment. — Surgical interference whenever practicable is 
important. The use of iodin and iodid of potassium in large 
doses has produced a cure in some cases. General supportive 
treatment is necessary. 

MILIARY FEVER, 

Definition. — An acute infectious disease, occasionally epi- 
demic, characterized by abrupt onset, profuse sweating, a 
peculiar exanthem, and constitutional symptoms. 

Synonyms. — Sweating sickness ; Schweissfriessel. 

The first occurrence of this disease was in i486, in the army 
of Henry VII, after its return from Bosworth field. The 
disease appeared epidemically, Hirsch having tabulated 194 
epidemics until 1874. In 1887 a severe epidemic occurred in 
France. The disease occasionally makes its appearance in 
parts of France and small portions of Italy. It has never 
been found in this country. 

Etiology. — Very little is known of the predisposing causes 



MILIARY FEVER. 289 

or of the exciting cause of this disease. Epidemics have oc- 
curred in spring and summer, and the disease appears to be 
more prevalent in damp and low-lying areas. The middle 
period of life appears to be predisposing. Women are more 
liable to attacks than men. The disease is not contagious. 

Period of Incubation. — The period of incubation is un- 
known. 

Pathology. — There are no characteristic lesions found after 
death. 

Symptoms. — Prodromes usually occur, consisting of head- 
ache, malaise, and weakness, the patient being first attacked 
at night, with profuse sweating, fever, and pain in the epigastric 
region. The elevation in temperature is moderate, — ioi° F. 
to 102 F., — and the pulse is rapid. There are tender points 
over the abdomen. After a variable period — usually from 
three to four days — an eruption appears, which increases the 
severity of the previous symptoms ; it consists of small reddish 
points of irregularly circular form, varying in diameter from 
one-half to one line. The eruption runs together and is con- 
fluent. A small vesicle soon appears in the center, which may 
enlarge to the size of a pea. The contents of the vesicle, at 
first clear, soon become opaque and purulent, and in two or 
three days crusts form that are soon cast off. The eruption is 
sometimes found upon the mucous membrane of the nose, 
mouth, and conjunctiva. As a rule, it first appears upon the 
neck and chest, thence upon the back and extremities. 

The cases differ in severity from the mild to the most 
severe types. In the gravest cases nausea, vomiting, delirium, 
and coma may occur, the patient dying in the so-called " ty- 
phoid " state. 

Convalescence, even from very mild cases, is prolonged. 

Diagnosis. — The diagnosis depends upon the occurrence 
of an epidemic, with appearance of sweating and the charac- 
teristic eruption. It must be carefully differentiated from 
malaria, variola, measles, and rheumatic fever. 

Prognosis. — The prognosis varies in different epidemics. 
Occasionally the disease has been very mild, and in some epi- 
demics the mortality has reached from 50^ to 80^. When 
death occurs, it usually takes place during the sweating stage. 

Treatment. — The treatment is purely symptomatic. Spe- 
cific treatment does not exist. Quinin in moderate doses 
seems to exert some influence. In convalescence tonics are 
required. 



290 INFECTIOUS DISEASES. 

MOUNTAIN FEVER. 

A disease has been described, occurring in mountainous 
regions, especially in the Rocky Mountains of the United 
States, with symptoms of extreme palpitation of the heart 
upon exertion, headache, giddiness, nausea, vomiting, marked 
dyspnea, and rapid pulse. These symptoms have been 
ascribed to the rarefied air. This condition must not be con- 
founded with the disease called mountain fever. 

The group of cases to which the term "mountain fever" 
has been applied present symptoms of an irregular continued 
fever. The duration of the attack is from two to four weeks 
or longer, and the temperature may vary between 10 1° F. 
and 104 F. 

It is most probable that this is a form of enteric fever or 
croupous pneumonia, as lesions of both these diseases have 
been found in cases dying from so-called " mountain fever." 

MILK-SICKNESS* 

Definition. — An acute disease particularly affecting cattle, 
occurring in man probably as a result of eating the flesh or 
drinking the milk of an animal so affected, characterized by 
great weakness, vomiting, constipation, twitching of the mus- 
cles, and other constitutional symptoms. 

Synonyms. — Trembles ; puking fever ; slows. 

Etiology. — Three theories have been advanced to explain 
the causation of the disease : (1) That the poisonous principle 
is furnished by a variety of rhus ; (2) That it is due to poison 
contained in the drinking-water of cattle ; (3) That it is due 
to a specific germ. It must be admitted, even at this day, 
that the etiology is still unsettled. 

Pathology. — Few opportunities have occurred for the per- 
formance of autopsy. The pathologic findings have been 
principally studied in cattle. Changes have been found in 
the cerebrospinal system, consisting of congestion and effu- 
sions of blood into the membranes. The liver and spleen are 
soft, and often enlarged and engorged with blood. The occur- 
rence of meningitis shows a possible analogy to cerebrospinal 
fever. 

Symptoms. — The symptoms occur abruptly, although the 
onset of the disease may be insidious. The principal symp- 
toms consist of the appearance of tremor, with marked mus- 



LEPROSY. 29 1 

cular weakness, vomiting, and fetor of the breath. The tongue 
is coated, dry, swollen, and fissured. Vomiting is a frequent 
symptom. The bowels are obstinately constipated, the pulse 
is full at first, but soon becomes small and rapid. The tem- 
perature may be slightly elevated, but in cases coming on 
abruptly the temperature may be subnormal. 

If death occurs, it is often preceded by symptoms of hiccup 
and delirium, finally passing into coma. 

Diagnosis. — It is most probable that this is a disease closely 
allied to cerebrospinal fever. 

Prognosis. — Favorable, depending upon the degree of 
toxemia. 

Treatment. — The treatment should be the same as in 
cerebrospinal fever. 



LEPROSY. 

Definition. — A chronic specific disease, characterized by 
cutaneous pigmentary changes and by the formation of neo- 
plasms in the skin, mucous membranes and nerves, which give 
rise to alterations in sensation, to ulceration, and to progres- 
sive deformity. 

Synonym. — Elephantiasis graecorum. 

The disease is known in various languages as leprosy. 

There is abundant proof that leprosy is an ancient disease ; 
a description of the disease corresponding to leprosy existed, 
according to Brugsch, at 4600 B. C, long antecedent to the 
Mosaic exodus. 

The disease still exists in certain parts of the world, and 
has occurred endemically in many places in the tropics, in the 
temperate zones, and even in the Arctic circle. 

Etiology. — Predisposing Causes. — The hereditary trans- 
mission of leprosy is still open to doubt. Many reliable ob- 
servers claim that it is hereditary, and, on the other hand, this 
is doubted by equally good authority. Poverty and improper 
hygiene have an undoubted effect on the disease. Improve- 
ment in the mode of living, proper food, and cleanliness have 
driven the disease out of the populous portions of Europe. 
No race is exempt, and the disease occurs in all climates. 

Exciting Cause. — The exciting cause is the bacillus leprae. 
(For description of the germ see p. 107.) Inoculation of the 
human subject with leprous tubercles has been successful. 
The disease is endemic in certain parts of the world. 



292 INFECTIOUS DISEASES. 

Pathology. — The postmortem changes show character- 
istic granulation neoplasms, the new growth being mostly 
made up of round cells, the bacilli being contained in 
the mass. The skin, the mucous membranes, nerves, lym- 
phatic glands, and various organs of the body show these 
changes. 

Period of Incubation. — This may extend through many 
years, and the period has not been definitely determined ; so 
much is, however, certain, that the period of incubation must 
be reckoned by years rather than by months. 

Varieties. — The disease has been divided into various 
varieties: (1) The nodular or tubercular form, in which the 
skin is primarily and chiefly affected ; (2) the smooth, in which 
the nerves are primarily affected ; (3) the mixed form, in which 
the lesions occur both in the skin and in the nerves. These 
varieties are not always distinct, one form readily merging 
into another. 

Symptomatology. — The Nodular or Tubercular Variety. 
— There are usually prodromes, which consist of an irregular 
rise in temperature, associated with lassitude, drowsiness, 
gastro-intestinal symptoms, headache, backache, sometimes 
bleeding at the nose, and, occasionally, profuse perspiration, 
associated with rigors. These may be slight or absent alto- 
gether. 

The first positive evidence of the disease consists in the 
leprous eruption, which appears as an irregular, shiny, ery- 
thematous patch of a reddish or copper tint, slightly raised 
above the surrounding skin, with infiltrations of the derma, 
accompanied by more or less hyperesthesia. The parts first 
affected are generally the lobes of the ears, the alse of the 
nose, the forehead, the eyebrows, the roots of the nose, and 
the lips ; in other words, the face is always primarily affected. 
Later, the eruption appears upon the extremities and the 
trunk. It may persist, or it may partially or even completely 
disappear for the time, but it invariably returns. Upon its 
return the well-marked leprous nodules show themselves as 
small papules that gradually enlarge, so that in course of 
time they may attain the size of a pigeon's egg. They appear 
upon the site of the former eruption. Small blood-vessels 
may sometimes be seen over the nodules. Occasionally, the 
entire body is invaded by this process. The hairy scalp, 
however, is rarely affected. This is known as the second 
stage of the disease. The nodules may now remain stationary 



LEPROSY. 293 

or may increase in size, in rare cases disappearing altogether. 
The face becomes characteristic, the region occupied by the 
eyebrows becomes prominent, and the forehead greatly thick- 
ened. A somber expression of the countenance is noticed. 

In a majority of cases the growth increases rapidly, fresh 
crops appearing from time to time, each being accompanied 
by a rise in temperature — from ioo° F. to 103 ° F. The 
lymphatic glands become prominent and painful, and the 
hands and feet are covered by the new growth, the nails 
dropping off. 

After this period has lasted a variable time the stage of 
ulceration sets in. In favorable cases some of the ulcers may 
heal, the patient living for some time ; in others the ulceration 
spreads by irregular tracts, bleeding taking place in the ulcer- 
ated nodules, especially upon the hands and feet. This con- 
dition may last for months or years, the patient dying from 
asthenia or visceral complications, such as renal disease or 
tuberculosis. 

The Smooth Variety (known as the Anesthetic or Atrophic 
Form). — The prodromes consist of alterations in sensation 
with trophic changes. These may be ill defined and come on 
slowly. There may be chilliness and general depression. 
Pain along the nerve-trunks is apt to occur, or if absent, may 
give place to numbness and tingling in the hands and feet. 
The sphincters may become affected. In some cases the 
eruption is the first symptom to appear ; it may be erythema- 
tous or pigmented. The spots are usually light copper or 
brown, or in the black races dirty yellow in appearance. 
The eruption commonly appears first upon the shoulders, 
back, loins, knees, elbows, and exceptionally upon the face. 
The face, however, may escape altogether. The eruption 
may follow the course of the musculospiral nerves. Fresh 
patches continue to appear, although the patient's health may 
not be otherwise affected. Usually, however, changes in sen- 
sation begin to appear, particularly anesthesia in the course 
of the ulnar nerves, more commonly in the left hand than in 
the right. 

New areas of the eruption begin to appear, although the 
original spots remain unchanged for several years. The hair 
falls out, and there is destruction of the sweat-glands. Per- 
spiration is absent in this variety. The superficial nerve-trunks 
may be felt enlarged beneath the skin. 

After an indefinite period the eruption ceases to be active, 



294 INFECTIOUS DISEASES. 

and there is no further deposit in the nerve -trunks. The 
disease may now remain stationary for a number of years. 
In the majority of cases, however, a continuous destruction 
of nerve tissues results, due to increasing leprous growth in 
the nerve -trunks. This gives rise to contractures. 

Arthropathies take place, resembling Charcot's joints. 
The bones may ulcerate, due to a lack of nerve supply. 
Ulcerations are common upon the fingers and toes ; the nails 
split and break. Eye affections in this form are due to lesions 
of the cranial nerves. 

Mixed Leprosy. — The symptoms in this form show a com- 
bination of the two just described. 

Diagnosis. — In the fully developed disease no difficulty is 
encountered in making a correct diagnosis. 

In countries where the disease exists, all new growths should 
be looked upon with suspicion, especially if combined with 
altered sensation. The finding of the bacillus is positive evi- 
dence. 

Prognosis. — The prognosis is grave, the disease being in- 
curable. 

Treatment. — Much may be done to prolong life and to 
mitigate suffering. Hygienic treatment is of the greatest im- 
portance — fresh air, well -ventilated and dry dwellings, and 
strict cleanliness are important. Extremes of heat and cold 
should be avoided. A good nourishing diet, consisting largely 
of fresh vegetables, should be given ; warm clothing is essen- 
tial, as the patients are very susceptible to cold and liable to 
disease of the kidneys. There is no specific treatment. 

The vegetable oils are most frequently employed, and 
oleum gynocardiae or chaulmoogra oil appears to be the best 
to increase perspiration, improve appetite, lessen anesthesia, 
and diminish pain. 

Arsenic is useful in some cases, and should be given to the 
point of tolerance. Ichthyol and resorcin have been advised 
by Unna. Thyroid extract has been efficacious in some 
cases. 

When gangrene occurs, amputation of the part may be 
necessary. Operations may be performed upon the leper 
without hesitation. Dead bone should always be removed. 
Nodules giving rise to obstruction should be excised. Trache- 
otomy prolongs life when the larynx becomes invaded and 
dyspnea is threatened. 



DYSENTERY. 295 



DYSENTERY. 



Definition. — Acute dysentery is a disease, principally of 
the large bowel, with or without fever, characterized by 
diarrhea, which is often bloody in character, with tormina and 
tenesmus. 

The term " dysentery " should be made to include all forms 
of alvine flux, either mild or severe, in which tormina and 
tenesmus are prominent symptoms (Trousseau). 

Synonyms. — Flux ; bloody flux ; Ruhr (German). 

Varieties. — On account of the diverse symptomatology, it 
has been necessary to arrange this disease into four principal 
varieties: (i) acute catarrhal dysentery ; (2) diphtheric dysen- 
tery ; (3) amebic or tropic dysentery ; (4) secondary dysentery. 

Etiology. — Climate is of great importance, as this is par- 
ticularly a disease of tropic and subtropic regions, the malady 
prevailing to a greater extent during the hotter months. All 
ages are susceptible, and if enterocolitis be considered dysen- 
teric in nature, it occurs as frequently in children as in adults. 
The male sex is more liable to the affection, on account of 
greater exposure, such as in camp life, armies, fleets, and 
prisons. 

This disease has been the most frequent cause of death in 
times of war, and Osier remarks that " it has been more fatal 
than shot and shell." Change of weather is an important 
factor, as sudden falls in temperature at night or exposure to 
heavy rain and dew, as frequently happens when camping upon 
the ground. Bad hygiene is probably one of the foremost 
predisposing causes. Overcrowding, irregular taking of food, 
bad water, especially if it be polluted, forced marches, and all 
conditions tending to lower the vital resistance may give rise 
to dysentery. 

Bacteriology. — Various forms of bacteria, but no constant 
one, have been found associated with dysentery. It has been 
claimed by many that the bacillus coli communis (see p. no) 
takes upon itself special pathogenic properties under certain 
conditions and produces this disease. It is probably due to 
the combination of various forms of bacteria with the absorp- 
tion of their ptomains. The amoeba dysenterica has frequently 
been found associated with tropic dysentery. 



296 INFECTIOUS DISEASES. 

ACUTE CATARRHAL DYSENTERY, 

Pathology. — This form most frequently terminates in re- 
covery, and postmortem studies have mostly been made where 
an intercurrent affection has produced death. 

The colon is most often involved, and the process may ex- 
tend as far as the rectum. Occasionally, the ileum and parts 
of the small intestine may also show the lesion. The mucous 
membrane is congested, swollen, and red, covered with a 
thick, opaque, yellowish or brownish mucus. The submucosa 
also is swollen and injected, pus being often present. The 
lymph nodes may be found enlarged. Ulceration may occur 
if the case be protracted. 

Symptoms. — The onset marked by chill and fever is ex- 
tremely rare, the attack beginning as an ordinary acute intes- 
tinal catarrh, which, after a few hours or days, takes on the 
additional symptoms of dysentery. These consist of pain 
and griping, commonly in the umbilical region and along the 
colon, accompanied by a dull pain in the loins. 

The stools at first may be either copious or scanty, soon 
becoming free from fecal material. There is frequent desire 
to have a passage from the bowel, accompanied by severe pain. 
This condition has been called tormina. However, spasms 
frequently occur at this time, and nothing but a slight amount 
of bloody mucus or pus is passed. This is known as tenesmus. 
The stools may consist entirely of blood mixed with mucus, 
and the association of pain with spasm may take place from 
every few minutes to half an hour or longer ; indeed, it may 
be almost continuous. After the first few days there are very 
slight, if any, constitutional disturbances, even if the local 
symptoms be quite severe. Later, there are loss of appetite, 
coated tongue, nausea, sometimes vomiting, with slight eve- 
ning fever — -100 F. to 10 1° F. This condition may continue 
for some time, the symptoms gradually ameliorating, or the 
symptoms may increase in severity and the disease pass into 
the diphtheric variety, or they may persist for a long time and 
become chronic. 

Prognosis. — In temperate climates under ordinary condi- 
tions the prognosis is almost invariably favorable. 

DIPHTHERIC DYSENTERY. 
Pathology. — The colon in the majority of cases is princi- 
pally affected, and the diphtheric process most frequently 
follows the acute catarrhal one. The diphtheric process varies 



DYSENTERY. 2 9/ 

greatly in extent as to firmness and tenacity of the exudate. 
The exudation is sometimes limited to the colon and the rec- 
tum, but occasionally the rectum alone is affected. It may ex- 
tend into the small intestine. In some cases the exudation is 
quite superficial, filling the follicles of Lieberkuhn. Most fre- 
quently, however, the submucosa is involved. Under the micro- 
scope the exudation has the croupous character. The loss of 
substance in the separation of the exudate is sufficient in some 
cases to cause ulceration. These ulcers vary in size from a 
slight abrasion to a deep excavation, which may invade the 
muscular coat of the bowel. Death may occur before the 
sloughing is completed. Perforation of the serous coat may 
occur, death being due to peritonitis. When healing takes 
place, the cicatrix is more or less puckered, and in rare in- 
stances stricture of the bowel results from this cause. 

Symptoms. — The disease may commence as an ordinary 
acute catarrhal dysentery, or it may begin abruptly, following 
an ordinary diarrhea, or the dysenteric symptoms may occur 
at once, without any preceding stages. It sometimes results 
from other acute or chronic diseases, and shows itself by the 
passage of blood and mucus. The patient becomes emaciated 
and weak, with symptoms of collapse, cold surfaces and ex- 
tremities, and marked increase in the cardiac action. The 
tongue is dry and fissured, and anorexia and thirst are promi- 
nent. The abdomen is tender to the touch and tympanitic. 
The skin may be slightly jaundiced, and the eyes sunken. 
With the occurrence of these symptoms a change in the 
character of the stool takes place. At first it consists of 
stringy mucus, more or less mingled with blood and pus. 
Yellowish or reddish masses, of various sizes, of the diphtheric 
exudate, which under the microscope are seen to be necrosed 
tissue, may be found. The passage of this diphtheric exudate 
is characteristic. There are great tormina and tenesmus. The 
urine is decreased in amount and often contains albumin. The 
disease may last from one to four weeks from the beginning 
of the dysenteric symptoms. Just prior to death the stools 
become brownish or black and are very offensive, and contain 
large amounts of necrosed tissue. 

The onset of the disease is sometimes accompanied with a 
chill, followed by fever, which may run to 103 F. or 104 
F., with marked abdominal symptoms. Nervous symptoms 
are rare. The patient rapidly passes into the typhoid condi- 
tion ; the pulse is rapid — 120 to 140 ; sordes collect upon the 



290 INFECTIOUS DISEASES. 

teeth, and the patient rapidly passes into collapse with the 
characteristic stool just described. 

When diphtheric dysentery occurs in the progress of a 
pre-existing flux, it may appear suddenly and rapidly prove 
fatal ; this is frequently the case after exposure to cold, indis- 
cretion in diet, and even sometimes without assignable cause. 
The characteristic stools develop, and fatal collapse is 
rapid. 

In chronic cases the stools show the diphtheric character 
later in the progress of the disease. The symptoms are not 
severe, and the case may end in recovery in from two to four 
months, or pass into chronic dysentery, in which the duration 
is indefinite. All these phenomena may be modified in differ- 
ent cases. 

AMEBIC (OR TROPIC) DYSENTERY. 

Pathology. — The large bowel is most frequently implicated, 
as the ameba has here the most favorable condition for its 
development. The small intestine may become infected ; in 
such cases the ameba passes from the large into the small 
bowel. The characteristic change consists in the great 
thickening of the intestine, which is usually more marked in 
the submucous coat, and may be confined to this part. The 
ameba is found in the discharges and is also present in the 
coats of the bowel. (For description of the ameba see p. 761.) 

Abscesses of the liver frequently result as a consequence 
of this condition. They are generally large and single, but 
two or three may occur in the same case. 

The infection is probably carried to the liver by the portal 
circulation, but this is disputed by some authorities. Abscess 
of the lung sometimes results. 

Symptoms. — Several varieties have been described, such as 
the mild, the grave, and the chronic, with masked symptoms. 
The onset is variable, with intermissions and exacerbations. It 
may be abrupt or gradual, the patient being suddenly attacked 
by severe pain in the abdomen. Diarrhea and nausea and 
vomiting are sometimes present, mostly without fever. The 
stools are frequent and watery, and blood, which may be present 
from the first, subsequently appears combined with mucus. In 
some cases abdominal symptoms may be absent altogether, 
and all the signs point to a hepatic or pulmonary abscess. In 
ordinary cases the tongue is pale and flabby ; the abdomen is 
usually normal in appearance ; the expression is dull ; nervous 



DYSENTERY. 299 

symptoms are absent. There is no fever ; the pulse may be 
from 70 to 90 a minute. Anorexia is present. 

The diagnosis depends upon the finding of the ameba in the 
discharges. 

SECONDARY DYSENTERY. 

Pathology. — The lesion in this variety is generally the same 
as described under the head of diphtheric colitis. 

Symptoms. — This is usually the terminal event in various 
chronic and acute diseases, such as cardiac affections, Bright's 
disease, smallpox, septicemia, and tuberculosis. The stools 
have the characteristic appearance of dysentery in general — 
blood and mucus. There may be from three to a dozen move- 
ments in twenty-four hours, and death may occur without 
symptoms of .tormina. Peritonitis is not infrequent. 

Complications. — The most usual complications are anemia, 
peritonitis, with an intestinal perforation, hepatic and pulmo- 
nary abscesses, pneumonia, tuberculosis, and malarial fever. 

Sequels. — Among the most important sequels of dysentery 
are fistulas from abscesses and hemorrhoids, with prolapse of 
the anus. 

Diagnosis. — The diagnosis depends upon the careful exami- 
nation of the stool. In the acute catarrhal variety there are 
blood and mucus ; in the diphtheric variety, the appearance 
of necrosed tissue ; in the amebic variety, the presence of the 
ameba in the evacuations ; in chronic dysentery, the associa- 
tion with some other important disease. 

Prognosis. — In the acute catarrhal variety the prognosis is 
favorable. In the diphtheric variety, especially that occurring 
in camp life, the mortality is often enormous : it may average 
from 50% to 80 f . The prognosis in children depends upon 
the age and the constitutional condition of the patient. Per- 
sistent high fever, vomiting, rapid wasting, and severe nervous 
symptoms are of unfavorable prognostic omen. The prognosis 
in the amebic form is always uncertain. 

Treatment. — Prophylaxis should consist in general hygiene, 
particular attention being paid to the drinking-water. Great 
care should be taken that there is no fecal contamination of 
the water-supply. It is considered good practice to give, 
early, a mild cathartic. The drugs that have given the best 
satisfaction are ipecac, opium, and the bismuth salts. Entero- 
clysis is of value in the management of dysentery. 



300 INFECTIOUS DISEASES. 



SYPHILIS. 



Definition. — Syphilis is an infectious disease, characterized 
by a primary lesion called a chancre, secondary manifesta- 
tions, and tertiary lesions. It may be either congenital or 
acquired. 

Etiology. — The disease in the majority of cases is trans- 
mitted by sexual intercourse. It may, however, be conveyed 
in other ways. Infection may take place in the practice of 
the physician or surgeon, he becoming accidentally inoculated 
by the examination of a syphilitic person. 

Vaccinal syphilis has occurred, but since the almost con- 
stant use of bovine virus this accident is rare. 

Syphilis has been acquired from the use of tableware, in- 
struments, or articles used by a syphilitic person* It has also 
been conveyed by kissing. 

Hereditary Transmission. — It occurs most commonly from 
the father, the mother being healthy (sperm inheritance). 

Maternal Transmission. — (Germ Inheritance.) — It is a 
well-known fact that a woman who has borne a syphilitic child 
may be immune. This has been stated by Colles, and is 
known as Colles' law : " That a child born of a mother who is 
without obvious venereal symptoms, and which, without being 
exposed to any infection subsequent to its birth, shows this 
disease when a few weeks old, this child will infect the most 
healthy nurse, whether she suckle it or merely handle and 
dress it ; and yet this child is never known to infect its own 
mother, even though she suckle it while it has venereal ulcers 
of the lips and tongue." A mother with acquired syphilis may 
have infected children and the father not be affected. In the 
greatest number of cases both parents are affected, the one 
having affected the other, in which case the fetal infection 
is greatly increased. 

If the mother be infected after conception, the child may be 
born syphilitic, although not necessarily so. This may occur 
through the placenta. 

Pathology. — Exciting Cause. — The specific cause has not 
been definitely determined, but the organism that at the pres- 
ent time has the best claim to recognition is the bacillus of 
Lustgarten. 

Chancre. — -This lesion consists of a number of round cells 
infiltrated into the tissue (perhaps the bacillus is intermingled 
in this mass). The blood-vessels in its locality undergo thick- 



SYPHILIS. 30I 

ening by connective-tissue formation. The tissue elements of 
the skin and subcutaneous tissues are usually surrounded by 
infiltrating liquid, and the latter may cause the exfoliation of 
the superficial epidermis and thus lead to the development of 
the ulcer so commonly seen. 

The induration of the initial lesion is due to the sclerosis 
of the vessels, newly formed connective tissue, infiltration of 
the embryonic cells, and liquid infiltration. 

Secondary Manifestations. — Secondary manifestations are 
numerous and very variable. The most important of these 
are the skin eruptions and the involvement of the mucous 
membranes and lymphatic enlargements. 

Tertiary Lesions. — The gumma, or tertiary lesion, strictly 
speaking, is the typical syphilitic manifestation. It consists 
of a central caseous area surrounded by a number of small 
round cells. 

Occasionally, some of these cells may be somewhat en- 
larged and are called epithelioid cells. Giant cells may also 
be found. The size of the gumma varies from that of a millet 
seed to the size of a walnut, and at times is even larger. 

The arteries near this lesion commonly show sclerotic 
changes. After a prolonged existence the gumma, if situated 
near a free surface, may discharge its caseous area and form 
an ulcer. Healing takes place by the formation of connective 
tissue leaving a cicatrix, which is frequently stellate. 

Site. — The liver, kidneys, spleen, bones (especially the 
tibia), brain, and nervous system are favored localities. 

ACQUIRED SYPHILIS, 

Symptoms. — The symptoms are usually divided into three 
stages : The primary, secondary, and tertiary stages. 

Primary Stage. — The period of incubation varies from ten 
to ninety days, the average being about three weeks, and the 
first symptom noted is the primary sore. This most gener- 
ally appears about a month after inoculation. It consists of a 
red papule that enlarges, leaving a small ulcer. The tissue 
surrounding it becomes indurated, so that it has a cartilagin- 
ous or gristly consistence, and is often called the hard or 
indurated chancre (Hunterian chancre). It varies in size and, 
when very small, may be readily overlooked, especially if it 
occurs within the urethra. The lymph-glands in the neigh- 
borhood of the chancre enlarge and become hard. Suppu- 
ration rarely occurs. There is usually no fever or decided 



302 INFECTIOUS DISEASES. 

impairment of health. The most common situation of the 
chancre is upon the external genitalia. Lymphatic enlarge- 
ment soon appears. 

Secondary Stage. — This makes its appearance within from 
one to three months, the average being about six weeks after 
the appearance of the chancre. There is fever, which is very 
variable, being either intense or the reverse, although most 
commonly it is mild. The fever often has a decidedly remit- 
tent character ; on the other hand, it may be intermittent. 
It may occur later in the disease, and be one of the tertiary 
symptoms. 

Anemia often of the chlorotic type is an important symptom. 
The first symptom noticed in the secondary stage is the 
cutaneous lesion, the most common being the macular syph- 
ilid or syphilitic roseola. This occurs on the abdomen, chest, 
and extremities ; the face may escape. It has a reddish-brown 
or coppery appearance. Other eruptions also occur : the pap- 
ular, pustular, and the squamous syphilid. Mucous patches 
develop. They are found upon the perineum, the groins, the 
axillae, between the toes, and at the angles of the mouth, and 
especially upon the mucous membranes. They are flat, 
warty outgrowths, and their surface is covered with a gray- 
ish secretion. The hair falls out. This may occur either 
in patches or there may be a general thinning, especially in 
the temporal regions. The nails may also become affected. 
Lesions of the mucous surface are very common. The 
tongue, the pharynx, and the tonsils may show characteristic 
syphilitic ulcers. Syphilitic warts or condylomata may occur 
in the genital regions and the anus. Other parts of the body 
may also be affected. Eye symptoms are very common, ear 
affections may occur, and general lymphatic enlargement is 
present. 

Tertiary Stage. — It is extremely difficult to say when the 
secondary manifestations cease and the tertiary begin. The 
special affections of the tertiary stage are gummatous growths in 
the viscera, certain skin eruptions, and rarely amyloid disease. 

The gumma may develop in the skin, subcutaneous tissues, 
muscles, bones, or internal organs. 

It is characteristic of the late skin manifestations of syphilis 
that there is a liability to ulceration. The most characteristic 
of these is rupia, which consists of dry, stratified crusts that 
cover the ulcer and that, upon healing, leave a permanent 
scar. 



SYPHILIS. 303 

Among the important symptoms of tertiary syphilis are 
bone-pains, which are especially marked at night. 

CONGENITAL SYPHILIS. 

The symptoms in this variety are similar to those already 
described, with the exception that the primary chancre does 
not exist. An apparently healthy-looking child may be born 
without showing any symptoms whatever of syphilis for a 
month or two. 

Pathology. — Among the lesions observed are sclerotic 
changes in the liver, lungs, spleen, pancreas, bones, and other 
organs. Skin manifestations are also encountered. The upper 
incisors are notched on the cutting surface, and are known as 
Hutchinson's teeth. 

Symptoms. — At birth the child is usually feeble, and the 
skin eruption may be present, showing itself particularly 
about the wrists and ankles and upon the hands and feet. 
The child snuffles. The mouth is fissured and the lips are 
ulcerated. The liver and spleen are enlarged, and bone symp- 
toms may be prominent. The epiphyses may be entirely 
separated. In such instances death may take place rapidly. 
Again, the child may thrive, become plump, and show no 
symptoms of syphilis whatsoever until some time between 
the second and third months, when nasal catarrh develops, 
interfering with respiration, and the characteristic snuffles 
show themselves. The nasal discharge may be seropurulent 
or bloody. Necrosis of bone takes place rapidly, and the nose 
undergoes characteristic deformity. Cutaneous lesions may 
develop about the same time. They are those that have 
already been described. 

Disease of the nails is frequent (syphilitic onychia). En- 
largement of the glands is not characteristic. 

The spleen is usually enlarged. The enlargement of the 
liver, however, is not so prominent. 

Hemorrhages are liable to occur ; the bleeding may be 
subcutaneous, from the mucous surfaces, or from the umbili- 
cus. The child does not thrive, but soon becomes cachectic 
in appearance, although this is not invariably the case. 

The teeth are deformed, as Hutchinson has pointed out. 
Eye affection is very common among the later manifestations, 
as is also middle-ear disease. Bone lesions do not occur 
until later — from the sixth year on. Gummata may occur in 
the brain, liver, kidneys, and other organs. 



304 INFECTIOUS DISEASES. 



VISCERAL SYPHILIS. 

Gummata may occur in the brain and spinal cord, and 
their meninges, in the lung, the liver, the digestive tract, the 
heart, the kidneys, and the testicles. 

Diagnosis. — The diagnosis is easy. This disease can 
scarcely be confounded with any other. In doubtful cases 
careful inspection should be made of the throat and skin for 
old lesions. The bones should be examined for nodes, and 
the scar of the primary sore should be looked for. In doubt- 
ful cases the therapeutic test may be resorted to. 

Prognosis. — In cases that are treated early the prognosis is 
favorable. 

Treatment. — Treatment should be begun as soon as signs 
of the secondary manifestations appear. The specific for 
syphilis is mercury and the iodid of potassium. Tonics are 
useful in the tertiary stage, and also in cachectic individuals. 

GLANDERS* 

Definition. — Glanders is an infectious disease due to a 
specific cause, occurring in animals, and exceptionally in man. 
It is characterized by enlargement of the lymphatic glands, 
especially the submaxillary and parotid chains, with symp- 
toms referable to the mucous membranes, particularly of the 
respiratory tract. 

Synonyms. — Farcy ; equinae ; Rotzkrankheit (German). 

Etiology. — All occupations that bring man into contact 
with domestic animals, especially the horse, predispose. For 
this reason the male sex is more frequently affected. Veteri- 
narians, hostlers, coachmen, etc., are particularly liable. The 
exciting cause is the bacillus Mallei, discovered by Loffler 
and Schutz in 1882. (For description of the germ see p. 107.) 

Pathology. — The cadaver presents the appearance common 
to pyemia ; the surface is covered with pustules, abscesses, 
and ulcers, particularly upon the face and extremities. It is 
peculiar of these excoriations that blood is present in them. 
In this respect they differ markedly from pyemic abscesses. 
Extensive erosions, which have been caused by cicatricial con- 
traction, and ulceration of the nasal tissues with necrosis of the 
nasal bones, are characteristic. Nodules are found in the 
respiratory tract, lungs, brain, liver, and spleen. These nodules 
are hard and firm, varying in size from small visable points to 



GLANDERS. 305 

a pea or walnut. On section, they are grayish white, having 
a yellowish-white center. This center is soft and caseous ; 
around this may be found epithelioid cells, leukocytes, and 
small round cells. Sclerotic changes are sometimes found 
around the nodules. The lymph-glands near the affected 
area may be enlarged and infiltrated. Erysipelas of the 
skin is common. Serous and seropurulent effusions occur 
in the joints and serous cavities. Occasionally, the effusions 
are hemorrhagic. 

Period of Incubation. — In artificial inoculation the period 
of incubation is a short one, being about twenty -four hours. 
In other cases it varies from three to five days. 

Symptoms. — The first symptoms are usually redness and 
swelling, which appear at the point of inoculation. Pain, 
with swelling of the neighboring lymphatics, occurs coin- 
cidently. Constitutional symptoms may precede this, con- 
sisting of chilly sensations, headache, prostration, and fever. 
The joints become painful and are red and swollen. This is 
characteristic of farcy. Red, hard nodules, varying in size 
from that of a pea to a walnut, soon appear upon the skin, 
and in some cases may resemble the eruption of smallpox. 
They soon break down, however, being rapidly formed, and, 
upon bursting, the pus is noticed to be very thick and fetid. 
The nodules may increase in size so that actual tumors are 
formed, which are known as farcy buds ; or ulceration, de- 
stroying the tissues to such an extent that the bone may be 
exposed. Occasionally, this process is extremely rapid, and 
may vary from a day to three or four weeks. 

Symptoms relative to the nose are less frequent in man than 
in the horse. Occasionally, there is ozena, and farcy buds 
may appear upon the nose. The whole respiratory tract thus 
becomes affected. Cough is prominent, accompanied by great 
dyspnea and profuse fetid expectoration. 

Fever may or may not be present. It may be very high, 
— 106 F., — with distinct variations such as occur in pyemia. 
A chronic variety sometimes shows itself with the same symp- 
toms as those just enumerated, excepting that the process is 
much slower and may last through years. When farcy buds 
appear in the internal organs, symptoms referable to these 
viscera occur. 

Diagnosis. — The diagnosis depends upon the exposure, 
the marked ozena, the nodular eruption, with formation of 
pus, and ulceration. The bacillus Mallei is found in the pus 



306 INFECTIOUS DISEASES. 

from the discharges, and in doubtful cases inoculation experi- 
ments should be performed. 

Mallein, which bears a resemblance to tuberculin in tuber- 
culosis, is used in veterinary practice for diagnosis in doubtful 
cases. A reaction always occurs if farcy is present, except in 
cases accompanied by fever. 

Prognosis. — The disease is invariably fatal in man, except 
in rare instances in the chronic variety. 

Treatment. — Prophylaxis is most important. When ab- 
scesses and ulcers form, strict antiseptic treatment is necessary. 
Tonics should be administered as a supportive treatment. 

FOOT-AND-MOUTH DISEASE* 

Definition. — A mild infectious disease occurring in animals 
and in man, particularly through infected milk. It is charac- 
terized by a slight fever, aphthous stomatitis, benign course, 
and short duration. 

Pathology. — Cases are rarely fatal ; ulcers form upon the 
mucous membrane, particularly of the cheek, tongue, and upon 
the hands. 

Period of Incubation. — The period of incubation varies 
from three to five days. 

Symptoms. — The disease begins with a chill or chilliness, 
anorexia, and high fever. The first symptoms noticed may be 
the appearance of vesicles upon the inner surfaces of the lips 
and tongue, having an inflammatory base ; coincidently, diffi- 
culty in chewing and speaking occur. This is followed by a 
vesicular eruption upon the fingers and hands, with perhaps 
slight gastro-intestinal disturbances. 

The vesicles are at first transparent, but upon increasing in 
size become purulent and may burst. The duration of the 
disease is from five to eight days, the majority of cases termi- 
nating in recovery. 

Diagnosis. — The diagnosis consists in the eruption of vesi- 
cles upon the buccal mucous membrane and hands, with fever. 
The knowledge of the disease existing among animals in the 
district is of importance. 

Prognosis. — The prognosis is almost invariably favorable. 
Few fatal cases have been reported, these having occurred in 
strumous and delicate children. 

Treatment. — Prophylaxis consists in boiling the milk. The 
disease should be treated by mild alkaline washes and a laxa- 



HYDROPHOBIA. 307 

tive dose of calomel at the onset ; if pain is prominent, the 
administration of small doses of Dover's powder or other form 
of opium is advisable. 

HYDROPHOBIA. 

Definition. — A disease of animals, especially of the dog, 
also occurring in man through inoculation, most often due to a 
bite. It is characterized by severe nervous symptoms, con-, 
sisting of spasm, with constitutional phenomena, and is very 
fatal. 

Synonym. — Rabies. 

Etiology. — Probably due to a specific germ not yet iso- 
lated, and always occurring in man through inoculation. The 
poison is contained in the saliva. The disease is probably 
due to an organism that multiplies in the tissues and produces 
a toxin that appears to act specially upon the central nervous 
system. 

Period of Incubation. — The period of incubation varies 
greatly. The disease may be latent, and no symptoms may 
occur for from ten to twelve months. In the majority of cases, 
however, symptoms will manifest themselves in from three to 
six weeks after the bite. 

Pathology. — There is congestion of the spinal cord and 
brain, and some exudation into the perivascular tissue. Hem- 
orrhages also take place in the cerebrospinal system. The 
mucous membranes of the respiratory system and gastro- 
intestinal tract and kidneys may be congested. The toxin is 
not found in the internal organs, such as the liver, spleen, and 
kidneys, but is quite abundant in the brain, the spinal cord, 
and the nerves. 

Symptoms. — At the end of the period of incubation the 
wound becomes painful, there is itching and tingling, with a 
sensation of heat, which may be accompanied by sharp pain 
following the course of the nerves. Occasionally, the wound 
may open afresh and an unhealthy purulent discharge make 
its appearance. Small vesicles may appear around the 
wound, which may ulcerate. 

In the early stages the patient is feverish and very thirsty, 
depressed and irritable. The muscles of the face are drawn, 
and there is a marked pallor and a peculiar look about the eyes. 
In talking, the speech may be interrupted by a sighing inspira- 
tion. The patient is unwilling to talk about the wound or bite 



308 INFECTIOUS DISEASES. 

that may have caused his illness. Sleep is disturbed. There 
is much thirst, and difficulty in swallowing, loss of appetite, 
nausea, and epigastric pain. The pulse becomes rapid, and 
the respirations are hurried and shallow. 

Upon the second or third day great nervous excitement 
appears. Delirium may occur. The pallor becomes more 
marked, the eyes are bright, and the mucous membrane of the 
mouth and fauces becomes congested. Upon these mucous 
surfaces an accumulation of thick, tenacious mucus will be 
noticed, which the patient tries to expel with a coughing sound, 
not unlike the bark of a dog. 

Thirst is prominent, but there is great difficulty in swallow- 
ing, especially of fluids. As attempts at deglutition are made, 
violent spasmodic contractions of the muscles occur. This 
may be followed by tetanic convulsions, with marked opis- 
thotonos and temporary cessation of respiration. The reflexes 
are increased, especially the tendon reflex. The symptoms may 
abate, only to recur again at an attempt to swallow, especially 
fluids. Slight causes may bring on the spasm, such as a sharp 
sound, a bright light, a breath of air, or the mere sight of 
water. The delirium is intermittent, but the patient in this 
condition may be brought to consciousness by the attendant. 

At first there is increased sexual desire, and later this symp- 
tom may become even more marked. The urine may contain 
sugar, albumin, and blood. The repeated attacks of spasm 
greatly exhaust the patient, and if the disease be protracted, 
wasting occurs. 

Diagnosis. — -The diagnosis depends upon the knowledge of 
a bite from a rabid animal. The appearance upon the second 
or third day of the peculiar spasm, with the bark, delirium, 
the occurrence of albumin and sugar in the urine, and the 
marked tetanic spasms. 

Prognosis. — The percentage of death varies from 5 % to 
50%. Since the introduction of the Pasteur treatment the 
mortality has been greatly reduced. When the symptoms are 
well developed, the patient almost invariably succumbs in from 
four to five days. 

Treatment. — The treatment consists in giving antispas- 
modics, such as chloral, bromid of potassium, cannabis Indica, 
and curare. Recently, most cases have been treated by the 
antirabic serum of the Pasteur Institutes. 



TETANUS. 309 



TETANUS. 



Definition. — An infectious disease, characterized by spasm, 
particularly of the muscles of the jaw, and other symptoms, 
relating to the nervous system. 

Synonym. — Lockjaw. 

Etiology. — The disease occurs in either sex and at any age. 
It may result from a wound in any part of the body and some- 
times without apparent trauma. It more frequently follows 
wounds of the extremities than wounds of the trunk. It 
occurs most often from injuries that are exposed to contact 
with earth or filth. The slightest causes may give rise to 
tetanus, such as a scratch, the extraction of a tooth, or the 
plugging of a nostril for epistaxis. It is more frequent in 
man than in woman, but it is said to be less fatal in the female. 

Exciting Cause. — The exciting cause js the bacillus of tet- 
anus, described by Kitasato. (For description of bacillus see 

P- JI 3-) 

Pathology. — Postmortem appearances are not characteristic. 
Congestion of the spinal membranes and nerves is usually 
found. The bacillus occurs in the neighborhood of the wound 
and not in the internal organs, as the toxins are responsible for 
the manifestation of the disease. 

Period of Incubation. — -The period of incubation is about 
two weeks. 

Symptoms. — The prominent symptoms are the occurrence 
and recurrence at varying intervals of tonic spasms of greater 
or lesser intensity in the voluntary muscles. The spasm may 
relax somewhat in sleep, but not entirely. It may commence in 
the neighborhood of the wound and spread over the remainder 
of the body. 

In man the spasm is usually first noticed in the neck, be- 
ginning like an ordinary rheumatic torticollis. This is soon 
followed by spasm of the muscles of the jaw, called trismus, 
with inability to open the mouth. The tongue may protrude 
between the teeth, and may be bitten by the violent and sudden 
closure of the mouth. The facial muscles show a strained 
appearance, which gives rise to the peculiar grin called the 
"risus sardonicus." 

The muscles of the abdomen become firm and contracted. 
There may be pain in the precordia, extending through to the 
back. The spasm affects the voluntary muscles ; the fingers, 
however, are rarely implicated. The pain is frequently not 



310 INFECTIOUS DISEASES. 

severe ; it may, however, in some cases be quite prominent. 
If pain be present, it is most acutely felt in the back, and an 
arching of the trunk backward may occur, called opisthotonos. 
Occasionally, emprosthotonos may take place, which is a 
bending forward, or to one side of the body, known as pleuros- 
thotonos. 

The muscles of the glottis may be affected, causing difficult 
noisy respirations and sometimes asphyxiation. In acute 
cases death occurs about the third day. In the less severe 
cases life may be prolonged for three or four weeks. Pro- 
tracted cases afford the best hope for recovery. 

The pulse is quickened during the seizures. The tempera- 
ture varies, — it may be from 99 ° F. to 101 F., or after pro- 
longed spasm hyperpyrexia may occur. High temperature 
may show itself just before the fatal issue. The mind is 
usually clear, although delirium has been noted in some cases. 
Profuse sweating is a prominent symptom of the disease. 

The urine is scanty and extremely toxic, often containing 
albumin. When injected into animals, tetanus is produced. 

Diagnosis. — In cases of trauma followed by tonic spasms 
the diagnosis is easy. Without the original focus, such as a 
wound, the diagnosis may sometimes be difficult. 

Prognosis. — The prognosis is unfavorable. In the pro- 
longed cases recovery may take place. 

Treatment. — Great effort should be made to administer 
nutriment, and rectal alimentation should be resorted to. 
Chloral is of some use in that it produces sleep and occasion- 
ally relaxes spasm. Antitetanic serum has been of value in 
some cases. The wound should be thoroughly cleansed and 
treated antiseptically. 

WEIL'S DISEASE. 

Definition. — A rare infectious disease, characterized by 
fever, jaundice, gastro-intestinal disturbance, and great pros- 
tration, occurring in limited epidemics. 

Synonym. — Acute infectious icterus. 

Etiology. — Very little is known of the disease, it being 
extremely rare. It has occurred in limited epidemics in pris- 
ons and camps, and it appears that unsanitary surroundings 
may be a factor in its production. The disease occurs more 
often in men, usually in the summer months. 

Pathology. — The lesions of granular degeneration occur- 



MALTA FEVER. 3 I I 

ring in other infectious diseases are found present in Weil's 
disease. Degeneration of the kidney and liver is prominent. 
Bacteriologic investigation has yielded no positive results. 

Symptoms. — The onset is marked by chill and a rapid rise 
in temperature. On the fourth or fifth day a remission 
usually occurs. The disease lasts three or four days longer 
than this, and defervescence comes on with a well-marked 
crisis. Occasionally, a relapse takes place. The pulse early 
in the disease is rapid and full, and as is so characteristic of 
jaundice, decreases in frequency as the disease advances. 
Prostration is a prominent symptom. Delirium and coma may 
occur, and there is usually mental dullness and apathy. Pains in 
the back of the neck and legs appear. The tongue is coated. 
There may be vomiting and either diarrhea or constipation, 
an enlarged and tender liver resulting in one-half of the cases. 

The spleen is early enlarged. Jaundice is invariably pres- 
ent, and may be the first symptom of the disease. It varies 
in intensity in different cases. The urine is decreased in 
amount, containing bile pigment, albumin, and hyaline and 
granular casts. The stools are clay colored. 

Complications and Sequels. — Catarrhal affections occur in 
the mucous membrane. Occasionally, purpuric manifestations 
are present. Secondary bubo appears in some cases. 

Prognosis. — The prognosis is generally good, death, how- 
ever, occasionally resulting. 

Treatment. — The diet should consist exclusively of milk. 
Violent purging should be avoided. Alkaline mineral waters 
should be used. In the early stages fractional doses of calomel 
should be given. Enteroclysis of cold water is useful in 
many cases. 

MALTA FEVER. 

Definition. — A specific infectious disease, due to the micro- 
coccus melitensis of Bruce, characterized by irregular fever, 
pain in the joints, free sweating, and other constitutional 
symptoms. The disease commonly lasts from three to six 
weeks. Relapses are frequent. 

Synonyms. — Mediterranean fever ; rock fever ; Neapolitan 
fever ; undulant fever. 

Etiology. — The disease appears to be endemic in Malta 
and parts of the Mediterranean coast. It has recently been 
noted as occurring in some of the islands of the Gulf of Mex- 
ico and in Puerto Rico. It especially affects young adults. 



312 INFECTIOUS DISEASES. 

The specific cause is the micrococcus melitensis of Bruce. 
(See p. 121.) Inoculation experiments have been successful 
in monkeys. 

The period of incubation is from a few days to twenty 
or thirty. 

Pathology. — The pathology is by no means settled. Perry, 
who made ioo autopsies of cases occurring in Gibraltar, found 
the typical lesions of enteric fever in every case. According 
to Bruce, the disease is rarely fatal, and upon autopsies no 
characteristic lesions are found. 

Symptoms.— The onset of the disease is characteristic, 
marked by prodromes. Some authorities describe the onset 
identically with that of enteric fever. There are headache, 
general malaise, loss of appetite, epistaxis, sleeplessness, and 
thirst. Diarrhea is not common. After a day or two of these 
symptoms slight chills occur, followed by more or less fever. 
The fever is often of a remittent type, lasting from one to three 
weeks. A period of apyrexia then takes place, which varies 
in duration from one to three days, and is followed by a relapse, 
in which marked rigors, high fever, delirium, diarrhea (the 
stools sometimes containing blood), and great prostration 
occur. The relapse may last several weeks and then, after a 
remission of a week or two, a second relapse takes place with 
a return of the initial symptoms. In the second relapse there 
are marked sweating, muscular and joint pains are more pro- 
nounced, and the prostration is extreme. The disease now 
often terminates in recovery, or after a lapse of one or two 
months all the symptoms may reappear. In severe cases the 
temperature is high, — 105 F., — its course subcontinuous, 
and death may be due to hyperpyrexia. Complications are 
rare. 

Diagnosis. — The disease may be differentiated from malaria 
by the microscopic examination of the blood. 

Prognosis. — The mortality is low, estimated at about 2%. 
The course of the disease may be very protracted, and may 
last six months or longer. 

Treatment. — The treatment is symptomatic. 



PART IL 

DISEASES OF THE CIRCULATION 



CONGENITAL MALFORMATION OF THE HEART. 

Aside from abnormality in the size and position of the 
heart, defects in its development and structure occur. The 
heart may even be entirely absent in some individuals called 
acardiac monsters. There have been instances in which the 
heart has been found in the neck or in the abdomen. It may 
lie immediately beneath the skin, only covered by the pericar- 
dium. The heart has been found in the right side of the 
chest, with the blood-vessels reversed, the venous blood enter- 
ing the left auricle, the pulmonary blood the right auricle, and 
the aorta having its origin at the right ventricle. This condi- 
tion is known as dextrocardia. It is usual in such cases to 
have the abdominal organs also reversed, so that the liver is 
found upon the left side and the spleen upon the right side. 

Complete absence or only a slight indication of the auricu- 
loventricular septum has been observed, in which the entire 
heart may consist of practically only two chambers, with one 
blood-vessel springing from each. Defects in the interauricu- 
lar and interventricular septa may be present. Stenosis of 
the pulmonary artery is the commonest of the malformations 
of the heart. Atresia cr obliteration of the pulmonary artery 
is a much rarer condition. 

The same conditions may be found in reference to the aorta, 
but are here even rarer than in the pulmonary artery. A 
patulous foramen ovale, or ductus Botalli, is by no means so 
rare. Valvular defects are common ; thus, there may be but 
two semilunar cups, and sometimes four have been observed. 
A similar state of affairs has been met with in the mitral and 
tricuspid valves. 

3i3 



3 H DISEASES OF THE CIRCULATION. 

Congenital deformity and fetal endocarditis are the most 
prominent causes of these conditions. With dextrocardia the 
individual may be perfectly normal otherwise. 

Symptoms. — The child is apt to be weakly, does not thrive 
well, and soon after birth presents signs of disturbance of the 
circulation, consisting of lividity of a bluish tint, affecting the 
face, hands, and feet. The respiration is labored and parox- 
ysmal, and is apt to be increased by screaming, suckling, and 
exposure to a cooler atmosphere. The extremities are cold 
and the terminal phalanges of both hands and feet are often 
clubbed. The surface temperature is subnormal, although the 
rectal temperature may be 99 ° F. 

Convulsions and cerebral attacks may take place indepen- 
dently of those induced by screaming, movement, and suck- 
ling, merging into coma, and often rapidly proving fatal. 

Cyanosis is by far the most common symptom and occurs 
in about 90^ of the cases. The blood shows marked altera- 
tions, the red corpuscles and the hemoglobin commonly being 
above normal. 

Physical Signs. — A loud, prolonged systolic murmur is 
heard all over the cardiac region, being transmitted in all 
directions. If there be stenosis of the pulmonary artery, a 
thrill will be noticed in the pulmonary area. 

Prognosis. — Grave in nearly all cases in which there is 
marked circulatory disturbance. 

Treatment. — The child should be kept warm and exertion 
should be controlled. General good hygiene is necessary. 
The treatment by drugs is unsatisfactory. 



DISEASES OF THE PERICARDIUM. 

PERICARDITIS. 

Divisions. — Acute and chronic pericarditis. 

ACUTE PERICARDITIS. 

Definition. — An acute inflammation of the pericardium. 

Etiology. — Etiologically, it may be divided into primary 
and secondary pericarditis. 

Primary Pericarditis. — Primary pericarditis includes those 
cases which can not be referred to any previous underlying 
disease. It is occasionally found in persons without apparent 



PERICARDITIS. 3 I 5 

cause, but such cases are extremely rare, and in the present 
state of knowledge they had better be classed as crypto- 
genetic. 

Those cases following injury, such as blows, wounds of the 
heart, or from internal causes, such as trauma of the esopha- 
gus, etc., may be classed as primary pericarditis. 

Secondary Pericarditis. — By far the greater number of 
cases belong to the secondary variety. In these rheumatic 
fever plays the greatest causative role ; it is associated with 
renal disease ; with extension from neighboring structures, as 
from the pleura or diaphragm ; with cardiac disease, such as 
myocarditis ; occasionally, with direct disease of the aorta ; 
with new growths, such as sarcoma ; and, finally, it is fre- 
quently associated with various diseases, such as scurvy, 
tuberculosis, scarlet fever, diphtheria, septicemia, erysipelas, 
gout, or diabetes. 

Pathology. — In acute pericarditis the visceral or the parietal 
layer may be involved ; often the condition is general or may 
be localized to certain areas. 

In the early stages the membrane becomes opaque, luster- 
less, and the surface roughened. Soon a fibrinous exudation 
appears upon the membrane or a serous exudate may result. 
The constant friction of the surface will cause a " honey- 
combed" condition of the fibrin or a " bread-and-butter " 
appearance. 

If the irritant be severe, a hemorrhagic exudate is present 
or it may go on to suppuration and a pyopericardium be 
produced. The inflammatory process may subside at any 
time during the process of the disease and the exudation be 
absorbed or it may in some cases be retained. When absorp- 
tion takes place, there are adhesions of the two surfaces, and 
fibrous connective tissue develops, called adhesive pericarditis. 
These adhesions may be general or local. General adhesive 
pericarditis, as a rule, causes hypertrophy of the heart ; rarely, 
atrophy results from the contraction of the connective tissue. 

Various micro-organisms are associated with acute peri- 
carditis, such as the staphylococcus pyogenes aureus, albus, 
or citreus, the bacillus coli communis, the bacillus typhosus, 
Klebs-Loffler bacillus, the bacillus of Pfeiffer, and others. 

Microscopically, the first change noticed in acute pericar- 
ditis is a parenchymatous degeneration of the endothelial cells. 
The blood-vessels under the endothelial layer show the 



3 16 DISEASES OF THE CIRCULATION. 

characteristic changes of acute inflammation. The exudation 
is formed as in all serous surfaces. 

Symptoms. — It is impossible to diagnosticate acute peri- 
carditis by symptoms, no matter how prominent they may be, 
without a careful physical examination. An accurate sympto- 
matic description of this disease is, therefore, impossible. The 
disease commonly begins with severe pain, of a sharp-stabbing 
nature, in the region of the precordium. In some cases it 
may be referred to the epigastrium or left nipple. The pain 
is more or less continuous, but varies in severity in individual 
cases. It is increased by pressure or by manipulating the 
chest, as in percussion or palpation. In rare instances it may 
be absent altogether. The respiration becomes embarrassed. 
The pulse-rate rises as the disease increases in intensity ; in 
the early stages it may be from 90 to 100, later it becomes 
more rapid, and in very severe cases may reach 160 a minute. 
In other instances the pulse-rate may be normal or the pul- 
sus paradoxus may be observed, especially with effusion. 

The respiration maybe hurried and shallow. With effusion 
actual dyspnea is present, and the patient usually lies upon the 
left side. Cough, which is irritable and spasmodic, commonly 
appears. There maybe difficulty in swallowing when the effu- 
sion is great, due to pressure on the esophagus. Fever of 
some degree is present in nearly all cases ; it is not typical, 
varying from ioo° F. to 103 F. 

Nervous symptoms, such as headache, sleeplessness, rest- 
lessness, etc., occasionally appear. If the effusion be purulent, 
edema in the precordial region may be noted and a septic 
temperature may be present. 

Physical Signs. — Inspection. — In the first or dry stage 
the apex-beat is seen in its normal position, and, unless there 
is an effusion, no bulging of the precordia will be noted. 

Palpation. — Palpation may elicit friction fremitus. This 
may be felt at any part of the heart, usually, however, at the 
base. It does not necessarily occur with systole or diastole, 
but may be noted independently. It is more superficial than 
an endocardial thrill, and gives the palpating hand the sensa- 
tion of being coarser. 

Percussion. — Percussion in the first stage gives normal 
cardiac dullness. When effusion takes place, depending upon 
its size, a flat area is found with its base at the apex of the 
heart, merging into the normal cardiac dullness as the base of 
the heart is reached. If the effusion be enormous, the entire 



PERICARDITIS. 317 

precordial area may be flat upon percussion. The area is 
usually pear shaped, with the base downward toward the apex 
of the heart. 

Auscultation. — In the first stage a friction sound is fre- 
quently heard, greatly varying in intensity. It may be de- 
scribed as rasping, coarse, or creaking in nature. It is limited 
to the precordial area, but may be heard at any part, most 
frequently, however, at the base. It usually occurs inde- 
pendently of systole or diastole ; then again, it may be entirely 
systolic or diastolic. If the sound be ill defined, change in 
the position of the patient may sometimes make it prominent, 
such as sitting erect or leaning forward, thereby bringing the 
pericardium nearer the chest-wall, thus intensifying the fric- 
tion sound. 

It is increased by pressure with the stethoscope, which also 
increases the pain. As the effusion develops, the friction 
sound gradually subsides, disappearing last at the base of the 
heart. As absorption of the fluid takes place, the friction 
sound gradually reappears. In w T ell-marked effusions the 
heart-sounds are distant, muffled, and may be entirely absent, 
particularly the first sound. The pulsus paradoxus frequently 
occurs, with large-sized pericardial effusions. 

Diagnosis. — This depends upon the occurrence of the pain 
in the cardiac region with the friction sound and the knowl- 
edge of some infective process. A pleural friction sound occa- 
sionally gives rise to difficulty in diagnosis, but when the 
patient holds his breath, the pericardial friction sound con- 
tinues, the pleural sound disappearing. Pleuropericardial 
friction sounds are sometimes encountered when both the 
pleura and pericardium are involved in the same process. 

Differential Diagnosis. — Differential diagnosis must be 
made between a pericardial friction sound and an endocardial 
murmur. (See p. 90.) 

Prognosis. — In uncomplicated cases recovery frequently 
takes place. Death may be due to a purulent effusion with 
symptoms of septicemia. 

Treatment. — In the first stage ice-bags applied over the 
precordium are of use in relieving pain and quieting the car- 
diac action. Large blisters should not be used over the heart 
as they interfere with systematic examination. Small blisters 
at some distance from the precordium, however, may be of 
benefit, .especially when there is an effusion. If pain be severe, 
opium in some form is necessary. In very large effusions 



310 DISEASES OF THE CIRCULATION. 

paracentesis is necessary, especially if the effusion be purulent ; 
in this condition surgical interference is imperative. Gentle 
purges from time to time are useful. A mild nonstimulating 
diet is indicated. 

SUPPURATIVE PERICARDITIS. 

Synonym. — Pyopericardium. 

Definition. — A purulent effusion in the pericardial sac. 

Etiology. — Pyopericardium may be acute in its onset or, as 
is more commonly the case, may result from a subacute or 
chronic process. It is rarely the outcome of simple acute 
pericarditis, in which case a serous or a serous fibrinous exu- 
date becomes purulent. In a large number of cases the pus 
may not be formed in the pericardium, but may be due to the 
accumulation of pus in a neighboring organ bursting into the 
sac, as in empyema of the pleura. It is always associated 
with pyogenic organisms. The longer a pericardial effusion 
remains unabsorbed, the more likely it is to become purulent. 
It may occur in connection with septicemia and pyemia, and 
occasionally in the course of the eruptive fevers, particularly 
smallpox ; it may be associated with injuries and diseases of 
the bones. 

If an abscess be formed in the myocardium, purulent peri- 
carditis may result. In malignant endocarditis it is excep- 
tionally found. The pericarditis associated with nephritis is 
supposed to have a special tendency to pus-formation. This 
has also been observed in tuberculous pericarditis. Pyo- 
pericardium is most common in young males. 

Symptoms. — The symptoms are the same as those occur- 
ring in serofibrinous or fibrinous pericarditis. 

Special symptoms are of no value in the diagnosis of pyo- 
pericardium, as it may occur with and without fever, and general 
septic phenomena ; indeed, the septicemia may entirely over- 
shadow the cardiac phenomena. 

Prognosis. — The prognosis is very unfavorable. 

Treatment. — The treatment is surgical. 

CHRONIC PERICARDITIS. 

Synonyms. — Chronic effusion ; adhesive pericarditis. 

Description. — Chronic pericardial effusion is extremely rare ; 
it may be of a hemorrhagic or purulent nature, and is generally 
associated with new growths or tuberculosis. 



PERICARDITIS. 3I9 

Pathology. — As the adhesions of fibrous connective tissue 
develop, hypertrophy of the heart becomes marked. In some 
instances the "ox heart" is produced. Adhesions of the 
visceral and parietal layers are frequently general. The pari- 
etal layer may also become adherent to the chest-wall, dia- 
phragm, or pleura. 

Symptoms. — Pain may be a prominent symptom of this 
condition, and gives rise to attacks of angina pectoris. In- 
ability to take a long full breath is sometimes a prominent 
feature, especially when the adhesions are extensive. There 
is marked disturbance of the cardiac action, and palpitation 
upon exertion is frequently a prominent symptom. Dyspnea 
is especially marked. Disordered function of the right ventri- 
cle is often prominent. It may come on gradually, becoming 
more and more pronounced, or may appear suddenly. This 
results in symptoms of dropsy, with congestion of the parts 
which relate to the portal circulation and _ the kidneys. The 
dropsy begins in the legs, but may involve the trunk and some- 
times the upper extremities. Cyanosis and distended veins 
may be prominent symptoms, or there may be pallor with puffi- 
ness of the face. The liver is enlarged and can be palpated 
below the ribs, being painful and tender. Symptoms relative 
to the digestive tract may become prominent, and the urine is 
diminished in amount and often albuminous. 

The symptoms just described may be entirely absent, even 
in well-marked cases. 

Physical Signs. — The diagnosis of pericardial adhesions 
can be made only by the physical signs. These may be very 
prominent or very obscure. They are likely to be better 
marked if the adhesions are extensive. In some cases there 
is a distinct depression, more or less marked, in the pre- 
cordial region, with narrowing of the intercostal spaces, the 
structures being drawn in by the external adhesions to the 
chest-wall. More commonly there is a bulging due to 
enlargement of the heart. The apex-beat presents differences 
in regard to its position and force : It may be noticed to the 
left of the parasternal line, even extending to the anterior 
axillary line, presenting all the evidences of great hypertrophy 
of the left ventricle. As a rule, it is carried outward, but it 
may be found in the fourth or fifth interspace, at the same time 
presenting evidences of great hypertrophy. On the other 
hand, the beat may be feeble or even imperceptible, with all 
the phenomena just described. This is attributed to the small 



320 DISEASES OF THE CIRCULATION. 

size and the weak action of the heart, being restrained by- 
adhesions or great thickening of the pericardium. 

Great variations of the situation, extent, and force of the 
impulse are noted. The impulse may extend upward through 
the entire precordial region, even reaching the second inter- 
costal space. Occasionally, it is impossible to localize the 
apex-beat. It may be strong and superficial, the impulse being 
noticed close to the chest-wall, especially if the condition 
occurs in children. The rhythm is markedly distributed, 
giving rise to great irregularity of the heart's action. When 
the heart is enlarged, the impulse is increased, even passing 
beyond its normal limits, tending downward toward the right 
in consequence of enlargement (dilatation) of the right 
ventricle. 

Systolic recession or retraction (dimpling) may take place. 
This sign is of great importance in pericardial adhesions. It 
may occur at the apex and be associated with the apex-beat, 
or may appear in one or more intercostal spaces to the left of 
the sternum, especially in the third, fourth, or fifth interspace. 
The movement may be wavy. 

When there is retraction at the posterior or lateral portion 
of the thoracic walls (interspaces), adhesions have usually 
formed with the diaphragm. They are noted during systole. 
This is known as " Broadbeni s sign." Broadbent described it 
as follows : " In cases of adherent pericardium, marked systolic 
retraction of some of the lower ribs on the lateral or pos- 
terior aspect of the thorax may sometimes be seen. This 
phenomenon is best seen when the patient is sitting up in a 
good light, and the movements of the chest are carefully ob- 
served from a short distance off, first from the front and then 
from the lateral aspect. When a pulsatile movement is seen 
over the lowest part of the left side posteriorly, it may at first 
sight appear to be expansile. On a more careful scrutiny it 
will be found that there is a tug on the false ribs during the 
cardiac systole and a sharp rebound during diastole, which can 
be felt as well as seen when the hand is laid flat upon the chest- 
wall at the spot ; it is more marked when deep inspiration is 
made ; it may be seen occasionally, not only upon the left 
side, but also on the right, especially if the patient leans over 
to the left." 

Sometimes there is diastolic shock. In well-marked cases 
it may be felt as a distinctive jerk or blow, occurring over the 



HYDRO PERICARDIUM. 321 

precordial area. It is a favorable sign in adherent pericardium, 
showing compensatory hypertrophy. 

Auscultation. — The signs upon auscultation may consist 
in the pericardial friction sound, which may remain. The first 
sound is often abnormal in character. It is sharp and fre- 
quently valvular, or may be dull and muffled ; occasionally it 
is prolonged and reduplicated. The second sound may also 
be reduplicated, and may cause diastolic shock. If adhesions 
form with the pleura, the pericardial friction sound may occur 
with inspiration and expiration. 

The pulsus paradoxus has been noted in this condition ; dur- 
ing diastole there is sometimes sudden collapse of the veins 
of the neck ; this is known as " Friedreich 's sign." 

The pulse will give the character of the condition of the 
ventricle : If the ventricle be markedly hypertrophied, the 
pulse will be full and strong ; on the other hand, if there be 
great dilatation of the ventricle, or if the contraction interfere 
with the movement of the heart, it is feeble. 

Diagnosis. — A positive diagnosis of adherent pericardium 
can only be made in the presence of the physical signs just 
enumerated. Severe heart symptoms in young persons, with- 
out valvular murmurs, point to pericardial adhesions ; whereas 
in persons of more mature age it is a sign of cardiac degen- 
eration. 

Prognosis. — Pericardial adhesions are not amenable to 
treatment. If slight, they may be of very little consequence. 
When they are marked and severe, the disease is one of great 
seriousness. Valvular disease complicating this condition adds 
to the gravity of the case. 

Treatment.- — Rest in the recumbent position is most 
important in preventing the great hypertrophy that is apt to 
take place. Cardiac tonics may be useful in some cases, but 
digitalis should be avoided unless signs of failure of compen- 
sation occur. Symptoms must be dealt with as they arise. 

HYDROPERICARDIUM. 

Synonym. — Dropsy of the pericardium. 

Pathology. — The amount of fluid contained in the pericar- 
dium may vary from a slight increase over the normal to a 
liter or more. It is a transudate ; the fluid is clear, straw 
colored, and of low specific gravity, — usually below 1018, — 
and the amount of albumin present is slight. It frequently 



322 DISEASES OF THE CIRCULATION. 

occurs in connection with general dropsy, as from kidney dis- 
ease or valvular heart disease. It may also occur with ane- 
mia, scurvy, tuberculosis, or allied conditions. 

In all the above-enumerated conditions, especially kidney 
disease (being most frequent in the chronic form of parenchy- 
matous nephritis), fluid is also found in the other serous 
cavities. 

Interference with the local circulation of the pericardium, 
such as thrombosis in the pericardial veins or from pressure, 
rarely gives rise to hydropericardium. 

Symptoms. — This condition can only be differentiated from 
pericardial effusion by the absence of friction sounds and the 
history of the case ; the other signs and symptoms being 
similar to pericarditis with effusion. 

Treatment. — The treatment consists in attention being 
directed to the cause. 



HEMOPERICARDIUM, 

Synonym. — Blood in the pericardium. 

Pathology. — This condition is rare, and results from exter- 
nal injury ; frequently, however, it is caused by an aneurysm 
of the aorta rupturing into the pericardial sac ; rarely aneurysm 
of the heart itself or from the coronary arteries may occasion 
it. Hemorrhages may result from purpura and allied condi- 
tions. The hemorrhage may occur from a small leak, the 
blood coagulating ; or it may be copious, distending the 
pericardial cavity suddenly. 

Symptoms. — Death may ensue rapidly if the quantity of 
blood poured into the pericardium be large. If it takes place 
more slowly, there may be pain, faintness, syncope, dyspnea, 
with rapid, feeble pulse due to lowering of the blood pressure, 
and the physical signs of accumulation of fluid into the peri- 
cardial sac. From lowering of blood pressure a decrease in 
the amount of urine, or anuria, may result. 

Prognosis. — The prognosis is hopeless. 

Treatment. — The treatment is entirely symptomatic. 



PNEUMOPERICARDIUM. 

Synonym. — Gas in the pericardium. 

Description. — This condition is extremely rare and results 
from perforation through the esophagus, lungs, or stomach, 



ACUTE ENDOCARDITIS. 323 

or from an external wound. Ulceration from a tuberculous 
cavity establishing communication with the pericardium may 
be a cause. In rare instances the gas-producing bacillus 
(bacillus aerogenes capsulatus) will be found associated. If it 
results from ulceration, pus may be found in the pericardial 
sac. Great distention of the pericardium will cause pressure 
upon surrounding structures. 

Symptoms. — If gas collects rapidly, there will be great 
precordial distress, dypsnea, cyanosis, and collapse, with 
irregular and feeble pulse. High fever with chills and profuse 
sweating may accompany this condition. 

Physical Signs. — The physical signs will depend upon the 
amount of gas in the pericardial sac. There may be bulging 
or fullness' in this region. The apex-beat may be weak or 
absent and better felt as the patient bends forward. A suc- 
cussion splash may occur upon shaking the patient if fluid be 
also present in the pericardium. 

Percussion may develop a note of metallic quality. The 
signs upon auscultation vary greatly. Metallic tinkling may 
be noticed ; bell tympany has been observed in some cases. 

Prognosis. — The prognosis is grave. 

Treatment. — The treatment consists in the administration 
of stimulants and sedatives. The question of operation pre- 
sents itself, and in suitable cases the gas may be let out by a 
fine trocar with the patient in the recumbent posture. This 
condition must be dealt with from a surgical point of view. 

NEW GROWTHS AND PARASITES OF THE 
PERICARDIUM. 

Tuberculosis of the pericardium has been described under 
Tuberculosis. (See p. 278.) 

Carcinoma is always secondary, and occurs from extension 
of neighboring organs. Sarcoma is met with, especially of 
the melanotic variety, and is most frequently secondary. 
Hydatids are extremely rare. 

ACUTE ENDOCARDITIS. 

Definition. — Inflammation of the internal lining membrane, 
or endocardium of the heart. This condition especially affects 
the valve segments. The walls are occasionally affected, when 
the condition is known as mural endocarditis. 



324 DISEASES OF THE CIRCULATION. 

Two varieties are recognized, acute and chronic. The acute 
is divided into two forms, — simple acute or benign, and the 
malignant or infective. 



SIMPLE ACUTE ENDOCARDITIS. 

Synonyms. — Benign, papillary, verrucose, or rheumatic 
endocarditis. 

Etiology. — The greatest number of cases are the result of 
acute rheumatic fever. This has been variously estimated as 
between 20°/o and 30% of all cases of rheumatic fever. It 
occurs more frequently in children than in adults, and usually 
appears during the first attack of acute rheumatic fever. If it 
does not result from the first attack it is almost invariably the 
consequence of the second or third attack. It appears in the 
milder as well as in the severer cases, and very frequently in 
patients who have not manifested prominent joint affection. 
Chorea sometimes gives rise to acute endocarditis. It appears 
in the course of the acute exanthematous fevers, scarlet fever 
occupying the first place. It is occasionally due to diph- 
theria, enteric fever, measles, smallpox, pneumonia, erysipe- 
las, puerperal and septic diseases, and sometimes as the re- 
sult of gonorrhea. Acute and chronic tuberculosis, gout, 
Bright's disease, and diabetes are etiologic factors. Trauma 
is also a cause of acute endocarditis. It must be stated that 
occasionally endocarditis arises apparently cryptogenetically. 
It occurs in fetal life, but here it usually attacks the right side 
of the heart. Age is important, as the affection shows itself 
most frequently between the ages of fifteen and forty, but is 
rare in old people, in whom valvular lesions are most often due 
to atheromatous changes. 

Finally, endocarditis may be secondary from extension of 
the disease from the myocardium or aorta. 

Pathology. —The lesions are usually situated in the left 
side of the heart. The endocardium lining the valves is 
affected in the following order of frequency : First, the mitral ; 
second, the aortic, and on the right side of the heart, the tri- 
cuspid ; and, lastly, the valves of the pulmonary artery. The 
endocardium of the valves is more frequently affected than the 
mural lining. 

The lesions are small vegetations, varying in size from 
one to four millimeters in diameter. They are small, warty, 
or cauliflower excrescences, — hence the name "verrucose" — 



SIMPLE ACUTE ENDOCARDITIS. 325 

and are most frequently situated on the valves at the line of 
contact, which in the mitral and tricuspid valves is the auricu- 
lar surface and in the aorta and pulmonary valves the ven- 
tricular. Usually, micro-organisms are associated with simple 
endocarditis. The following are the most important : Staphy- 
lococcus, streptococcus, gonococcus, diplococcus of pneumo- 
nia, Eberth's bacillus, bacillus coli communis, and the bacillus 
of Pfeiffer. 

Microscopically, the first change noted in the endocardium 
is the granular degeneration of the endothelial cells. In the 
subendothelial tissues, blood-vessel changes that accompany 
inflammation are noted. Coagulation necrosis and the pro- 
liferation of the fixed cells are found. The inflammatory 
exudate in the subendothelial tissues and the fibrin upon the 
free surface causes the bulging or warty excrescence. Upon 
this projection fibrin from the blood stream is also deposited. 
Intermingled with the exudate the various micro-organisms 
just enumerated may be present. 

Simple acute endocarditis may terminate in organization, 
but it is questionable whether complete recovery without de- 
formity of the valve ever results. Most frequently, the con- 
dition terminates in chronic sclerotic endocarditis with marked 
deformity of the valve segments, which remains permanently. 
Occasionally, the simple acute variety terminates or merges into 
the malignant. Destruction of the warty excrescence, such as 
breaking off and forming an embolus, rarely happens in the 
simple form. 

Symptoms. — The disease may come on without giving rise 
to any symptoms, the subjective phenomena varying greatly 
in intensity and the physical signs usually only appearing after 
the disease has become chronic. Attention may only be at- 
tracted to the endocardium by an attack of hemiplegia due 
to embolism. If the disease follow acute rheumatic fever, 
the symptoms will be largely those due to the infection, and 
the endocarditis can cnly be diagnosticated by the physical 
signs. 

In other instances during the attack of an infectious disease 
symptoms of oppression, with uneasiness and pain in the car- 
diac region, may appear. The pulse may become small and 
quick, and the heart's action tumultuous. Dyspnea upon 
exertion is a symptom of some importance. If pericarditis 
complicate this condition, pain is likely to be a prominent 
symptom. 



326 DISEASES OF THE CIRCULATION. 

Physical Signs. — Physical signs may be very marked in 
some cases, and in others absent altogether. 

Early on inspection no change is usually noticed, and the 
trustworthy and important physical signs can only be discov- 
ered upon auscultation. As the mitral valve is most frequently 
involved, a systolic murmur, which has its maximum intensity 
at or near the apex and is transmitted to the left axilla and often 
to the angle of the scapula, shows that mitral regurgitation has 
taken place. The murmur is at first soft and blowing in char- 
acter. Its occurrence may be preceded for a few days by an 
impurity and a prolongation of the first sound. In children 
the signs are more marked, as a rule ; tumultuous, quickened, 
and uneven heart-sounds, which are sometimes reduplicated, 
appear. 

If the endocarditis affect the aortic valves or if the vegeta- 
tions be small, no special signs may be present ; or, again, a 
diastolic murmur will appear at the aortic cartilage, which is 
transmitted down the sternum, showing that aortic incompe- 
tence has taken place. Stenosis of either the mitral or aortic 
valve is rare. This condition most often occurs in the chronic 
form of endocarditis. 

In rare instances the right side of the heart may be affected 
and murmurs, which relate to the tricuspid or pulmonary 
valve, make their appearance. 

Complications. — -The most frequent complications are peri- 
carditis, myocarditis, and occasionally pleurisy and pneu- 
monia. Emboli and infarcts are more likely to arise in malig- 
nant endocarditis, in which case the valve may entirely recover 
its normal function. In the majority of instances, however, 
the physical signs, when once well marked, do not disappear. 

If compensation be complete, symptoms do not arise, and 
it often happens that only with failing compensation attention 
is directed to the heart. 

Death may result from large pericardial effusions, hyper- 
pyrexia, or toxemia, or the disease may be converted into ma- 
lignant endocarditis. 

Diagnosis. — The diagnosis depends entirely upon the phys- 
ical examination. The presence of well-developed murmurs, 
which remain stationary and which are conducted in definite 
directions, all indicate some permanent valve defect. In the 
absence of a well-defined murmur in the course of acute rheu- 
matic fever, any symptoms that point directly to the heart 
should be carefully investigated, for even in the mildest cases 



INFECTIVE ENDOCARDITIS. 327 

of acute rheumatic fever, in which little or no joint affection 
occurs, the heart is extremely likely to suffer. 

Differential Diagnosis. — The differential diagnosis between 
an organic murmur and a functional murmur may occasionally 
give rise to difficulty. The functional murmur is most fre- 
quently heard at the left base ; it is not transmitted ; it is 
always systolic in time, and accompanies anemic conditions. 

The commonest seat of acute endocardial disease is at the 
mitral valve, the murmur being heard at the apex and trans- 
mitted to the left axilla, and often to the angle of the scapula. 

Prognosis. — Death in simple endocarditis during the acute 
stage is due either to the severity of the primary disease or to 
some complication. A large number of patients recover from 
the acute attack, but become subjects of chronic valvular 
disease. When acute endocarditis occurs in persons affected 
with valvular disease, the prognosis is, more serious, as in 
fresh outbreaks the disease is likely to be infective or 
malignant. 

Treatment. — The treatment consists in absolute rest in the 
recumbent posture. Local applications of ice, especially when 
pericarditis is present, are of use. Digitalis should only be 
given for definite and fixed indications, and is not required 
unless the pulse becomes quick and small or irregular, or 
signs of failing compensation occur. Strychnia is of benefit in 
this condition. If anemia persists, iron with quinin and arsenic 
will be found valuable. 



INFECTIVE ENDOCARDITIS. 

Synonyms. — Malignant endocarditis ; ulcerative endocar- 
ditis ; mycotic endocarditis. 

Etiology. — -The conditions that give rise to simple endo- 
carditis also give rise to malignant endocarditis. This variety 
of endocarditis is due either to the great amount of toxemia or 
the great preponderance of organisms in the process. 

Pathology. — The pathologic changes that occur in infective 
endocarditis are very similar to those of simple or benign 
endocarditis. The virulence or the number of micro-organisms 
is probably greater, the process more rapid, and destruction 
of tissue more pronounced, so that it is common in this con- 
dition to have infected emboli swept through the blood-current, 
lodging in the various organs, and producing infarcts and em- 
bolic abscesses. The endocardium on the left side of the heart 



328 DISEASES OF THE CIRCULATION. 

is, again, most commonly involved ; that lining the valves more 
often than that of the wall, and the same order of frequency 
occurs regarding the valve affected as in the simple acute 
variety. 

The vegetations are frequently large, projecting into the 
cavities of the heart, with a ragged, irregular surface, and very 
friable. Very often ulcers are found as a result of the break- 
ing down of the vegetation, the myocardium being involved in 
not a few cases. Abscesses of the myocardium may form, as 
a consequence of which aneurysm or rupture of the heart may 
result. The chordae tendineae and papillary muscles are often 
destroyed. 

Microscopically, the same changes will be noted as in acute 
simple endocarditis, except that the process is more extensive. 
Through extension the pericardium may be inflamed. Various 
micro-organisms and their toxins, especially the latter, are 
often present in the blood. Leukocytosis is almost constantly 
found. 

Symptoms. — The symptoms vary, and the cardiac phe- 
nomena may be slight, insignificant, or even absent. In other 
cases the symptoms are pronounced and readily call attention 
to the fact that the heart is affected. 

On account of the great variety of symptoms four special 
types have been recognized. The symptoms of each type, 
briefly considered, are as follows : 

Septic or Pyemic Type. — This occurs during the course 
of septicemia, pyemia, sometimes in the puerperal state, or in 
the course of any severe septic infection. 

The onset is acute, without prodromes, the disease being 
ushered in by chills, fever, and sweating, which may be re- 
peated after a longer or shorter interval. The temperature, as 
a rule, is of the remittent type. The skin may show patches of 
erythema or purpuric manifestations, or may contain superficial 
collections of pus. The pulse is rapid and feeble ; the respira- 
tion, shallow and quickened. Headache, delirium, and coma 
are the nervous symptoms most often present, and at times 
hemiplegia due to cerebral embolism occurs. The tongue is 
dry, brown, and furred. Anorexia, with vomiting and great 
tympanites, is present. 

Abscesses are likely to form in various organs and tissues. 
The patient may present no cardiac signs ; or, on the other 
hand, there may be murmurs, which vary in intensity and 
duration. Albuminuria, pain and swelling of the joints, with 



INFECTIVE ENDOCARDITIS. 329 

suppuration, sometimes take place. Death occurs in from 
one to two weeks. 

Typhoid Type. — This closely resembles enteric fever, show- 
ing the same conditions of the tongue, the same abdominal 
symptoms, and marked nervous symptoms. Not infrequently 
rigors are present ; petechias occur, and optic neuritis is a 
symptom. This rarely occurs in enteric fever. 

The physical signs relating to the heart may be very indefi- 
nite or may be absent. The temperature is irregular, and 
rigors occur throughout the attack, followed by profuse sweat- 
ing. Embolism of the brain, kidney, or spleen is common. The 
disease may last from two to four weeks, terminating fatally. 

Cerebral Type. — The affection shows itself by symptoms 
relating to the cerebrospinal system, particularly headache, 
somnolence, rapidly passing into unconsciousness and coma, 
with delirium and convulsions. Chills and fever are rarely 
present, but embolic processes may call attention to the heart, 
although the cardiac phenomena be not well marked. 

Cardiac or Malarial Type. — The majority of cases of 
ulcerative endocarditis are of this variety and appear in per- 
sons affected by some form of chronic endocarditis. It may 
run a subacute or chronic course, and last for months and even 
a year. 

Recovery is extremely rare, most cases proving fatal. The 
onset is insidious with prodromes or general malaise. A slight 
increase in the temperature may be one of the earliest symp- 
toms. The disease may resemble rheumatic fever with pain 
in the joints, but in either case chills soon occur, with fever 
and sweating. 

The temperature may show either a remittent or intermittent 
type, and 104 F. or even higher ranges have been noted. 
The chills occur at irregular intervals, and several days or even 
weeks may elapse before a second rigor appears. In this 
variety embolic processes are most likely to occur. These 
may take place in the peripheral arteries, in the middle cerebral 
artery, or any of its branches, sometimes causing permanent 
hemiplegia. Splenic infarct is common, occasionally with- 
out giving rise to symptoms. A symptom that should at 
once call attention to this condition (splenic infarct) is a sud- 
den sharp pain in the region of the spleen with an increase in 
splenic dullness upon percussion. Renal and pulmonary in- 
farcts also occur. Pains in the joints are common ; petechias 
and hemorrhage from the mucous membranes are met with, 



330 DISEASES OF THE CIRCULATION. 

especially if the aortic valves are affected. Hemorrhages into 
the retina and optic neuritis are extremely common in this 
condition. The urine shows traces of albumin and blood 
with epithelial and granular casts. The liver and spleen re- 
main enlarged. The bowels may be constipated, but profuse 
diarrhea with hemorrhages from the bowel occasionally occur. 

Symptoms relating to the heart are most common in this 
condition, and murmurs at any of the valves may appear. 
These murmurs are characterized by their changeable nature, 
now appearing at the mitral and now at the aortic valves. 
They may be either soft or harsh in character. Palpitation, 
cardiac pain, and excessive dyspnea may occur. 

Complications. — Pneumonia, pleurisy, pericarditis, cerebral 
hemorrhage and aneurysm are the most frequent complications. 

Diagnosis. — The diagnosis depends upon the presence of 
fever, which may be either of a remittent or intermittent type, 
with chills and marked sweating ; anemia is constantly pres- 
ent. Enlargement of the spleen and liver occurs. Changes 
take place in the retina with optic neuritis, as do also hemor- 
rhages into the mucous membranes and skin. Hematuria 
from renal infarcts and other signs of infarcts, with bacterio- 
logic examination of the blood with the inconstant and change- 
able valvular murmurs, and leukocytosis are characteristics of 
this condition. The appearance of a right-sided involvement 
should call attention to infective endocarditis, as this is ex- 
tremely rare in the simple variety. 

Prognosis. — The prognosis is very unfavorable. 

Treatment.— No drugs are known that have any influence 
on this condition. If the infection be due to the streptococ- 
cus, the antistreptococcic serum will usually be of value, sev- 
eral successful cases having been reported. The treatment 
should be supportive and tonic. The measures that have been 
advocated in simple endocarditis may be of use also in this 
condition. 

CHRONIC ENDOCARDITIS. SCLEROTIC ENDOCARDITIS. 
MITRAL INSUFFICIENCY. 

Synonyms. — Mitral incompetency ; mitral regurgitation. 

Definition. — A diseased condition of the mitral valve or of 
the left auriculoventricular opening, forcing the blood into the 
left auricle with the contraction of the ventricle. 

Etiology. — Acute rheumatic fever is the primary cause 
leading to the greatest number of cases of mitral insufficiency. 



CHRONIC ENDOCARDITIS. 33 I 

Extreme anemia with changes in the muscular substance of 
the walls of the left ventricle, diminishing its contractile power, 
may result in this condition. It may be due to stretching of 
the auriculoventricular orifice accompanying dilatation of the 
left ventricle, which is secondary to changes at the aortic ori- 
fice. Occasionally, disease of the columnar carneae and chordae 
tendinae, which allow the flaps of the valve to pass beyond 
the plane of the orifice, gives rise to mitral incompetency. It 
is encountered at all ages, but is most frequent in the young. It 
is most often the result of acute endocarditis passing into 
chronic endocarditis. 

Pathology. — The most frequent lesion is a shortening or 
thickening of the chordae tendinae, preventing proper closure. 
Rarely, there may be stretching of the chordae tendinae, caus- 
ing a lengthening and an overlapping of the mitral segments. 
Other sclerotic changes, such as one or more segments becom- 
ing united, may reduce the elasticity, often converting them 
into a firm band. 

Calcareous infiltration, especially at the base of the mitral 
segments, is quite common. Acute or chronic myocarditis may 
prevent proper closure. As a result of the improper closure 
blood regurgitates into the left auricle during the ventricular 
systole, first producing increased tension in the pulmonary 
veins with dilatation of the left auricle, which is soon followed 
by hypertrophy of this chamber of the heart. The left ven- 
tricle now receives more blood and hypertrophies. The in- 
creased pressure in the pulmonary circulation throws more 
work upon the right ventricle, which, in turn, hypertrophies. 
In this way compensation may be maintained. Sclerotic 
changes in the pulmonary artery and veins and brown indu- 
ration of the lung result from the increased tension in the 
pulmonary circulation. 

Symptoms. — Unless rupture of a valve or of the chordae 
tendinae occur suddenly, the symptoms may be latent for a 
long time. Especially is this the case if compensation be well 
established. Only with failing compensation do the following 
symptoms make their appearance : dyspnea, especially upon 
exertion ; cough ; expectoration which is frequently tinged 
with blood ; decreased amounts of urine containing albumin ; 
and gastro-intestinal disturbances. The pulse may remain 
regular in force and rhythm. This condition must be diag- 
nosticated by the physical signs. 

Physical Signs. — Inspection. — The area of cardiac impulse 



33 2 DISEASES OF THE CIRCULATION. 

is greatly increased and more or less distinct, depending upon 
the hypertrophy of the right ventricle. . Especially in children 
will there be bulging of the precordium, with a heaving of the 
thoracic wall. 

Palpation. — The apex-beat is displaced to the left ; the 
impulse is diffused and more or less forcible, depending upon 
whether the hypertrophy of the right or left side predomi- 
nates. A systolic thrill, most distinctly felt at the apex, in 
rare instances may be found. This is almost always associated 
with a presystolic thrill, showing coexisting mitral stenosis. 

Percussion. — The area of cardiac dullness is increased later- 
ally and downward. 

Auscultation. — A systolic murmur, which has its maximum 
point of intensity at or near the apex, being transmitted to £he 
left axilla and angle of the scapula, is diagnostic of this con- 
dition. It is usually soft and blowing in character, and may 
become distinctly musical. Accentuation of the second pul- 
monary sound is characteristic. This is heard particularly at 
the second left interspace. Mitral stenosis frequently coexists 
with this condition. In such cases a presystolic murmur and 
a presystolic thrill will be present at or near the apex. 

Diagnosis. — The diagnosis depends upon the recognition 
of a systolic murmur at or near the apex, transmitted to the 
left axilla, often to the angle of the scapula, with accentuation of 
the second pulmonary sound, and changes in the heart-muscle. 

MITRAL STENOSIS, 

Synonyms. — Narrowing or obstruction of the mitral valve. 

Definition. — In this condition the blood passes with diffi- 
culty from the left auricle to the left ventricle. Frequently 
stenosis coexists with insufficiency of the mitral valve, and it 
is questionable whether stenosis occurs separately and apart 
from mitral regurgitation. 

Etiology. — Mitral stenosis is almost invariably the result 
of valvular endocarditis occurring in children and young 
adults. It is rarely seen after the fiftieth year. It is nearly 
twice as prevalent in females as in males. A limited number 
of cases seem to be congenital. Acute rheumatic endocar- 
ditis is the most frequent cause. 

Pathology. — Narrowing of the mitral orifice results from 
sclerotic changes in the valve segments so that they are 
united ; contraction results, and there is produced a condition 



MITRAL STENOSIS. 333 

commonly called a "buttonhole" mitral valve. This is al- 
most invariably associated with some degree of incompetence, 
as the valve segments are entirely obliterated and a band-like 
ring is present. As a result of this narrowing, dilatation of 
the left auricle, which is soon followed by hypertrophy, oc- 
curs. This hypertrophy is marked, the muscular wall being 
three or four times its normal thickness. 

The increased pulmonary tension causes more work for the 
right ventricle, and hypertrophy of this chamber follows, 
which is marked in this lesion. The left ventricle, in a major- 
ity of the cases, is not hypertrophied, because it has less work 
thrown upon it, receiving even less blood than normal. Atro- 
phy of this chamber has been noted. Similar changes result 
in the pulmonary arteries, veins, and lung as have been de- 
scribed in mitral incompetency. 

Symptoms. — Few subjective symptoms are present unless 
compensation is ruptured. The patient is usually anemic, and 
precordial pain may be a symptom. The pulse is small, feeble, 
rapid, and irregular. Attacks of fainting may take place, due 
to the brain not receiving sufficient blood. 

Physical Diagnosis. — Inspection. — The cardiac impulse 
is feeble and indistinct. It is rarely seen to the left of its 
normal area, and is usually most distinct in the fourth inter- 
space near the sternum. 

Palpation. — The apex-beat is feeble. A distinct, purring, 
presystolic thrill, at or slightly above the apex, is frequently 
communicated to the hand. It may begin during diastole 
and run up to the ventricular systole, when it ceases abruptly. 

Percussion. — The area of the cardiac dullness may be 
slightly increased to the right and upward. 

Auscultation. — A loud, blubbering, presystolic murmur at 
or near the apex is diagnostic of this condition. The murmur 
is longer in duration than any other murmur. It is synchron- 
ous with the purring, presystolic thrill, and is heard slightly 
above the apex, being louder when the patient is sitting than 
when reclining in a recumbent position. It is not transmitted. 
The second pulmonic sound is accentuated and occasionally 
the second sound is reduplicated. When mitral incompetency 
coexists, a systolic murmur is also present, the presystolic 
and systolic murmurs constituting one. The presystolic mur- 
mur is always harsher and longer than the systolic murmur. 

Diagnosis. — The diagnosis depends upon the feeble, small, 
rapid pulse, the presystolic thrill and presystolic murmur, 



334 DISEASES OF THE CIRCULATION. 

having its point of maximum intensity slightly above the apex, 
with a marked accentuation of the second sound. The pre- 
systolic murmur is not transmitted. 



AORTIC INSUFFICIENCY, 

Synonym. — Aortic regurgitation or incompetency. 

Definition. — This condition is produced by an abnormal 
state of the aortic valves or dilatation of the aortic orifice, 
which prevents complete closure during the cardiac diastole, 
and allows a backward current of blood to flow from the aorta 
into the left ventricle. 

Etiology. — It is most frequently found during the middle 
periods of life in vigorous athletic persons. Acute endocardi- 
tis is rarely a cause, unless it be due to the malignant form, 
in which case death rapidly results. The common causes are 
fibroid change leading to thickening, induration, and contrac- 
tion of the valves. Syphilis is often the cause of this con- 
dition. Congenital insufficiency is very rare. 

This lesion frequently occurs in persons subjected to violent 
muscular exertion — those engaged in the various trades and 
occupations that require heavy lifting and great muscular force. 
Athletes are often subject to this form of valvular disturbance, 
in whom it may lead to sudden death. 

Pathology. — Aortic insufficiency may result from congeni- 
tal defects, as absence of one of the cusps. Sclerotic changes 
often develop, causing a shrinkage of one or more of the seg- 
ments or their complete obliteration into a fibrous mass, pro- 
ducing stenosis as well as insufficiency. Calcareous infiltration 
is very commonly associated with this sclerotic change. Athe- 
roma of the aorta may interfere with the closure of the valve. 
Aneurysm of the first part of the arch of the aorta causes a 
relative insufficiency. Rupture of a leaflet may produce it. 
As a result of insufficiency, the left ventricle is called upon 
to do more work, as the arterial blood flows into the ventricle 
during diastole, so that it must handle this as well as blood 
received from the auricle. Hypertrophy, in consequence, 
follows, which often assumes enormous proportions. 

The left auricle has more work thrown upon it, and as a 
consequence hypertrophies ; finally, the right ventricle shows 
hypertrophy as a result of the increased pulmonary tension. 
The hypertrophy of the heart in aortic regurgitation reaches 
immense proportions, the heart frequently weighing 600 



AORTIC INSUFFICIENCY. 335 

grams. This is called the ox heart (" cor bovinum "). Dilata- 
tion of the aorta and carotids as well as aneurysm may result. 
Sclerotic changes are sometimes found in the mitral valve, and 
the papillary muscles may be flattened. Sclerosis of the 
coronary arteries, followed by changes in the myocardium, 
such as fatty degeneration, frequently take place. Chronic 
interstitial myocarditis may also be found, as well as general 
sclerotic changes in the arterial system and kidneys. 

Symptoms. — This condition may exist for years without 
giving rise to symptoms, and only with loss of compensation 
do they appear. Palpitation, especially upon exertion, is 
usually the earliest indication. The pulse in this disease is 
characteristic. It is known as the " Corrigan," ''receding," 
or "water-hammer" pulse. It is large and distinct and sud- 
denly projects against the finger ; at the time when arterial 
tension sinks, the impulse vanishes abruptly. Its characters 
become especially noted when the arm is raised above the 
head, as this favors the receding character. It is always 
regular in rhythm while compensation lasts. A delay in the 
pulse is noted. This pulse is due to the nonsupport of the 
great quantity of blood thrown out by the hypertrophied left 
ventricle, the aortic valves not closing perfectly and permitting 
regurgitation. Angina pectoris sometimes occurs in this con- 
dition. Tinnitus aurium may also be a symptom. 

Physical Signs. — Inspection. — Inspection shows a forcible 
and increased cardiac impulse. The apex-beat is displaced 
downward and to the left, often reaching the seventh inter- 
space in the anterior axillary line. The vessels of the neck 
are seen to pulsate forcibly, as do also the superficial vessels, 
particularly the temporals. The capillary pulse occurs in 
aortic incompetency. 

Palpation. — This confirms inspection. The impulse is for- 
cible, heaving, and may be perceived over the entire cardiac 
area. 

Percussion. — The area of cardiac percussion is increased 
downward and to the left. 

Auscultation. — A diastolic murmur, with or taking the 
place of the second sound, heard with greatest intensity at 
the aortic cartilage, and sometimes at theensiform, transmitted 
down the sternum, is characteristic of this condition. It is 
sometimes heard loudest at the xiphoid cartilage. Occasion- 
ally it is transmitted toward the apex. This murmur is more 
greatly diffused than any other organic murmur, and may 



33^ DISEASES OF THE CIRCULATION. 

occasionally be heard even in the arteries of the neck. It may 
be soft and blowing, or rough, and occasionally musical in 
character. A presystolic murmur, known as the " Flint mur- 
mur," is sometimes heard at the apex. This is due to one of 
two causes, or a combination of both. According to Sansom 
and Potain, " It may be due to the impingement of the reflu- 
ent aortic current on the anterior mitral curtain before it is 
made taut, whereby vibrations are set up in the valve itself, or 
by bulging the valve the orifice is practically narrowed" 
(Allbutt). The first sound is loud and booming in character, 
as occurs in all cases in which there is hypertrophy of the 
ventricle. In this form of valvular disease sudden death is 
likely to take place from rupture. 

Diagnosis. — This depends upon the characteristic pulse 
(Corrigan pulse), the diastolic murmur heard at the second 
right costal cartilage, transmitted down the sternum, and the 
great hypertrophy of the left ventricle, with the capillary pulse. 

AORTIC STENOSIS. 

Synonyms. — Aortic narrowing ; aortic constriction. 

Definition. — A diseased condition of the aortic valve, caus- 
ing more or less narrowing of this orifice with hypertrophy of 
the left ventricle. In nearly every instance this valve lesion is 
associated with some degree of insufficiency. 

Etiology. — It is a disease of advanced life, and is often as- 
sociated with arteriocapillary fibrosis. Rheumatic fever may 
give rise to the double lesion at the aortic valve. Increased 
tension of the aorta and prolonged muscular exertion may be 
the causative factor in the changes at the aortic orifice, espe- 
cially in persons of a gouty diathesis ; particularly is this so in 
females. Aortic valvular disease is not commonly of rheu- 
matic origin. 

Pathology. — Fibrous changes along the edges of the aortic 
cusps, extending throughout the valve segments, may cause a 
slight degree of obstruction, as well as incompetency. The 
most marked obstructive lesion is produced by fibrous indura- 
tion at the base of the valve cusps, causing a contraction and 
thereby narrowing the orifice. Calcareous infiltration into the 
sclerotic area not infrequently follows. Recurrent acute endo- 
carditis may follow upon an old lesion. 

As a result of the lesion of stenosis, the left ventricle first 
dilates and then is followed by marked hypertrophy, which, 



AORTIC STENOSIS. 337 

next to the lesion of aortic regurgitation, shows the greatest 
thickening of this part of the heart. Subvalvular stenosis, or 
a lesion of the endocardium, in the left ventricle, causing some 
obstruction to the outflowing blood, has been noted. Aortic 
stenosis may result from fetal endocarditis. 

Symptoms. — Few if any symptoms occur, provided com- 
pensation be established, and quite extensive stenosis is not 
incompatible with a fair degree of health, if there be sufficient 
hypertrophy of the left ventricle, enabling the heart to fill the 
arterial system and relieve pulmonary pressure. 

Pallor, cold hands and feet, shortness of breath upon exer- 
tion, impaired nutrition, vertigo, and nausea may be symptoms. 
The pulse is normal or below the normal in frequency, but 
may be quite strong and forcible (pulsus tardus). It may be 
quite regular in rhythm, but occasionally it is intermittent and 
jerky. Embolic processes in the brain are more often associated 
with aortic stenosis than with any other chronic valvular lesion. 

Physical Signs. — Inspection. — The area of cardiac impulse 
is increased, the apex being displaced outward and downward. 
In old persons in whom emphysema is prominent there may 
be no visible impulse. 

Palpation. — Palpation confirms inspection. A systolic thrill 
is often felt in the region of the second right intercostal space, 
or in the neck. This thrill is usually well marked. 

Percussion — The area of cardiac dullness is increased to 
the left and downward. 

Auscultation. — A systolic murmur is heard at the second 
right costal cartilage and transmitted into the vessels of the 
neck. The first sound of the heart may be heard, but the 
murmur either replaces or obscures it. It is loud and harsh 
in character, and usually loudest at the beginning of the sys- 
tole. The second sound of the heart is often obscured. This 
murmur follows the direction of the blood current, and may 
be heard over the thoracic and abdominal aorta or other large 
arteries. 

Diagnosis. — The diagnosis depends upon the systolic mur- 
mur heard at the second right costal cartilage, transmitted into 
the vessels of the neck, accompanied by a systolic thrill in the 
aortic area, with a hard, commonly slow pulse, and consider- 
able hypertrophy of the left ventricle. 

It should be remembered in this connection that anemic 
murmurs, which are also systolic in time, may be heard in this 
area. Murmurs which are due to dilatation and roughening of 



33$ DISEASES OF THE CIRCULATION. 

the aorta also occur in this area, but in none of these condi- 
tions is a systolic thrill present. 

TRICUSPID INSUFFICIENCY. 

Synonyms. — Tricuspid incompetency ; tricuspid regurgi- 
tation. 

Etiology. — This may be the result of an endocarditis which 
has thickened and puckered the valve, often congenital. Any 
condition of the lungs which produces dilatation and hyper- 
trophy of the right ventricle may lead to it. It is met with in 
pseudohypertrophic pulmonary emphysema and in advanced 
cases of chronic bronchitis. It is most frequently secondary 
to some mitral lesion. 

It occasionally is the result of an infective endocarditis, 
occurring during the course of gonorrhea, puerperal fever, etc. 
In such conditions it is primary. 

Pathology. — The valves may be shrunken and thickened, 
due to chronic changes produced by rheumatic fever, but more 
often the consequence of atheroma following ventricular pres- 
sure. This may result in mitral disease, disease of the lung, 
or from chronic renal disease (granular kidney). 

Obstruction in the pulmonary circuit causes dilatation of the 
right ventricle, and in this way produces relative incompetency 
'of the tricuspid valve. General venous obstruction may follow, 
and symptoms of cyanosis and dropsy make their appearance. 

Symptoms. — The symptoms may be entirely masked by 
an accompanying affection of the left side of the heart. It will 
be noticed, however, that as soon as the valve becomes insuf- 
ficient the venous return is impeded. Cardiac palpitation, 
dyspnea, and irregularity in force and rhythm of the heart 
occur. The area of splenic and hepatic dullness is increased. 

Dyspeptic symptoms become marked, and obstinate con- 
stipation is the rule. Headache, dizziness, and vertigo are 
symptoms showing cerebral congestion. While the patient is 
in the recumbent posture the face becomes turgid and cyanotic. 
The urine is scanty, dark, and of high specific gravity, often 
containing albumin. Dropsy shows itself in the later stages 
of the disease, beginning in the feet and continuing until there 
is anasarca. 

Physical Signs. — Inspection. — The area of the cardiac 
impulse is very extensive. It may be seen from the left nipple 
to the ensiform cartilage. Pulsation may be seen in the jugu- 



TRICUSPID STENOSIS. 339 

lar veins. The veins of the face, arms, and hands may- 
pulsate. 

Palpation. — The apex-beat is feeble and diffused, with a 
distinct epigastric pulsation. 

Percussion. — Percussion shows an increase in the area of 
cardiac dullness to the right and upward. 

Auscultation. — A systolic murmur is heard in the region 
of the ensiform cartilage. It is of low pitch, soft, and often 
faint. The murmur is frequently transmitted slightly to the 
right. In pure tricuspid regurgitation the pulmonary second 
sound is not accentuated. The liver often pulsates, and a 
murmur may be heard in this area. 

Diagnosis. — A murmur heard at the ensiform cartilage, 
systolic in time, and slightly transmitted to the right, not 
accompanied by accentuation of the second pulmonary sound, 
with jugular and epigastric pulsation, points to tricuspid 
regurgitation. 

TRICUSPID STENOSIS. 

Synonyms. — Tricuspid constriction ; tricuspid narrowing. 

Etiology. — This is frequently congenital, rarely acquired 
in origin, and is often associated with malformations of the 
heart, and accompanied by tricuspid regurgitation. 

The prominent symptoms are lividity of the face, dyspnea, 
vertigo, edema, with scanty and albuminous urine. 

Physical Signs. — Upon inspection congestion of the body 
is prominent. The impulse can be seen in the epigastric re- 
gion. A negative venous pulse is noted in the neck. A 
thrill may be felt in the tricuspid area. The cardiac area is 
increased upward and to the right. 

A presystolic murmur is heard upon auscultation, at or 
near the xiphoid cartilage. This may be heard faintly toward 
the base, but never toward the apex. 

Diagnosis. — The diagnosis of this condition can only be 
made by excluding other valvular lesions. 

PULMONARY INCOMPETENCE. 

Etiology. — This valve lesion is very rare, and may be the 
result of injury, or congenital malformations of the heart. 

At the second or third interspace to the left of the sternum 
a loud diastolic murmur is present, which becomes weaker in 
intensity as the apex of the heart is reached. 



340 DISEASES OF THE CIRCULATION. 

Gerhardt has recently called attention to a reduplicated 
heart-sound which may be heard over the lungs. 



PULMONARY STENOSIS. 

Etiology. — This condition is extremely rare, and may be 
due to endocarditis occurring during uterine life. It is almost 
always a congenital affection. Congenital syphilis has been 
supposed to be a causative factor. 

Pathology. — Fibrous adhesion of the valve segments is 
most often the cause of pulmonary stenosis. 

Symptoms. — Palpitation, dyspnea, cyanosis, and edema 
are the prominent symptoms when this occurs. 

The condition must be diagnosticated by the occurrence of 
a systolic murmur heard in the pulmonary area. It is not 
transmitted upward or downward. The second pulmonary 
sound may be absent or weak. Hypertrophy of the right 
ventricle accompanies it. The diagnosis must be made by 
excluding other valvular lesions. 

Prognosis of Chronic Valvular Diseases. — So long as 
compensation remains established, even though the valve 
lesion be a serious one, the outlook for the patient is good. 
With signs of failing compensation the slightest valve lesion 
becomes serious. Age is important, as the condition is most 
unfavorable in young children. As the valve lesion may go 
on to progressive changes, repeated attacks of the exciting 
cause — most often rheumatic fever — may occur. 

When valve lesions appear in early adult life, compensation 
is most apt to become established and remain so for a long 
time. When valve lesion develops in the aged, the prognosis is 
good, as few urgent cardiac symptoms are likely to develop. 

The male sex does not bear valve lesion as well as the 
female. Intercurrent diseases render the prognosis unfavor- 
able. 

The most serious valve lesion — and for practical purposes 
the left side of the heart need only be considered — is aortic 
regurgitation. This is frequently associated with angina pec- 
toris, and, on account of the great hypertrophy of the left 
ventricle, sudden death from rupture of the heart may take 
place. Next may be considered aortic stenosis, but this valve 
lesion is rare, and usually occurs in those past middle life 
and in old age. Mitral stenosis is next in order, and the least 
serious of all valvular conditions is mitral regurgitation. 



PULMONARY STENOSIS. . 34 1 

Treatment of Chronic Valvular Diseases. — The treat- 
ment of valvular disease should be divided into three periods. 

First. — The period of complete compensation, in which no 
drugs are required. 

Second. — The period of failing compensation. 

Third. — The period of complete rupture of compensation. 

In the first period the patient should, if possible, lead a 
quiet life free from excitement The diet should be of a light, 
nutritious, easily digested character, great care being bestowed 
upon the condition of the bowels. The patient should be in- 
structed never to strain at stool. Alcohol and tobacco had 
better be avoided, and if used at all they should be taken 
sparingly. Exercise is essential, but should not be prolonged 
to fatigue. Bathing is useful, but the Turkish bath should 
not be permitted. Sexual indulgence in the majority of cases 
should be entirely abstained from. The patient should avoid 
attacks of bronchitis, and if possible should live during the 
winter in a warm, even climate. It is well, under these con- 
ditions, to let some member of the family or an intimate friend 
know that the patient is suffering from valvular disease of the 
heart. 

The first signs of failing compensation are dyspnea upon 
exertion, palpitation, and slight edema of the feet ; — an ex- 
amination of the patient will show that hypertrophy and dila- 
tation have been making progress. Rest in bed is now impera- 
tive. The use of calomel in broken doses, in cases of this sort, 
is often of advantage. If great signs of dilatation take place, 
digitalis in some form is a useful drug. It may be given either 
in the form of an infusion or of the tincture, or digitalin may 
be used. Strychnia in small doses is also beneficial in this 
condition. 

In aortic insufficiency, when there is great vascular ten- 
sion, nitroglycerin is often the best drug. If dyspnea is 
marked, rest in bed should be advised. Morphin, cautiously 
administered in small doses, often gives great relief. If there 
be much fluid in the pleura, aspiration, may be resorted to. 
Dropsy should be treated by the administration of calomel, 
salines, and digitalis. Hot-air baths, or pilocarpin, in this 
condition, are not advisable. Southey's tubes may be used to 
relieve the edema. 



342 • DISEASES OF THE CIRCULATION. 

COMBINED VALVULAR LESIONS* 

It would be a great mistake to suppose that valvular lesions 
only occur singly ; combinations of any and all the forms 
described may occur. The diagnosis of such lesions naturally 
becomes complicated. An important point in the recognition 
of such conditions is to endeavor to find the primary seat of 
the cardiac affection. The primary valve lesion should, if 
possible, be diagnosticated. 

Frequently mitral regurgitation and stenosis are combined ; 
on the other hand, aortic regurgitation and stenosis occur 
together. It is most common for the mitral and aortic seg- 
ments to be affected together. The next in frequency are 
combinations of mitral and tricuspid lesions, and then aortic, 
mitral, and tricuspid lesions. 

Aortic regurgitation and stenosis are more often encoun- 
tered than mitral regurgitation and stenosis. 

EFFECTS OF VALVULAR DISEASE. 

When compensation is maintained, very little disturbance 
manifests itself in other organs, but from long-continued val- 
vular disease, especially after repeated attacks of failing com- 
pensation, organic lesions result in other organs. This is 
brought about by the failure of blood pressure, being de- 
creased in the arterial tree, and a backward pressure mani- 
festing itself in the venous radicals. 

The lungs, liver, kidneys, spleen, stomach, intestines, brain 
and heart-muscle suffer most. When failing compensation 
occurs, edema first manifests itself in the dependent parts of 
the body, usually appearing about the ankles, then gradually 
extending up the limbs, in the arms, and may become general 
(anasarca). Atrophy of the heart-muscle, accompanied by 
pigmentation, frequently results from long-continued conges- 
tion, called brown atrophy of the heart-muscle. The heart- 
muscle in this condition becomes indurated and of a yellowish 
brown color. 

As a result of high blood tension in the pulmonary circu- 
lation, brown induration of the lungs develops ; they become 
indurated, the blood-vessels dilated, and there is pigmentation 
in the interstitial substance and alveolar epithelium. Edema, 
congestion, pulmonary apoplexy, bronchitis, and pneumonia 
are not infrequent complications. 



EFFECTS OF VALVULAR DISEASE. 343 

The symptoms resulting from the foregoing conditions are 
usually manifested in cough, dyspnea, or orthopnea, and occa- 
sionally hemoptysis. In valvular heart disease, chronic bron- 
chitis and repeated attacks of acute bronchitis are not uncom- 
mon. Edema and congestion of the lungs are commonly late 
manifestations, occurring usually before death. 

Pulmonary tuberculosis not often follows valvular heart 
disease. The reverse, however, is not true, as endocarditis not 
infrequently results as a complication of pulmonary phthisis. 

The liver, as a result of long-continued congestion, becomes 
atrophied, the condition being called cyanotic atrophy, or red 
atrophy. The appearance of the liver in this condition is 
much altered. It is larger than normal, of a deep purple 
color, and on section is mottled, revealing what is called the 
"nutmeg" appearance, or the liver of heart disease. 

This mottling is due to the dilated central veins of the 
lobules, and causes atrophy of some of the surrounding liver- 
cells and a deposit of pigment in these cells. Around this 
congested area the liver more or less retains its color, or 
becomes lighter, due to fatty infiltration. When the tricuspid 
valve becomes incompetent, pulsation of the liver frequently 
results, the impulse being transmitted directly through the 
venous circulation. The area of liver dullness is increased. 
Fatty infiltration of the liver sometimes exists in chronic 
valvular disease. 

The kidneys also show similar alterations as a result of the 
change in blood pressure, the condition being called cyanotic 
induration. The organ becomes large and indurated, of a 
deep purple color. 

The urine shows marked changes, due to cyanotic indura- 
tion. The total quantity is greatly diminished and it becomes 
albuminous, and casts and blood make their appearance. 

The spleen also becomes enlarged and congested. Infarcts 
are common in the spleen and liver. 

The stomach and small intestines become congested, and 
the mucous membrane reveals catarrhal inflammation. As a 
result of this, digestive disturbances manifest themselves, 
which are also somewhat influenced by the changes occurring 
in the liver. The appetite begins to be impaired ; there is pain 
after eating, and constipation frequently occurs. The small 
intestines also show similar changes. Hemorrhage into both 
the stomach and kidney are often encountered. 

The brain, from failure of compensation, becomes edema- 



344 DISEASES OF THE CIRCULATION. 

tous, fluid collects in the subarachnoid and ventricular spaces, 
and the veins become distended. As tricuspid regurgitation 
develops, occurring usually from dilatation of the right heart, 
pulsation becomes apparent in the veins, this being most 
marked in the veins of the neck. 

The dropsy of heart disease begins around the ankles or in 
the pretibial space, and gradually extends upward. The 
external genital organs frequently show marked edema, caus- 
ing obstruction in the urethra as a result of pressure. This 
often produces annoying symptoms. Pain becomes marked, 
and inflammation not infrequently results. 



HYPERTROPHY OF THE HEART. 

Definition. — An increase in the thickness of* the walls of 
the heart, accompanied by increased functional activity with 
or without alteration of the capacity of its chambers. It may 
be limited to a single chamber, or to one side, or may affect 
the entire heart. Hypertrophy of the left ventricle is the 
commonest of these conditions. Next in order of frequency is 
hypertrophy of the left auricle, then the right ventricle, and 
lastly the right auricle. 

This occurs in two forms, simple hypertrophy, and hyper- 
trophy with dilatation, called " eccentric " hypertrophy. 

Simple hypertrophy consists in an increase in the amount 
of the heart muscle, its cavities remaining unaltered. 

Hypertrophy with dilatation consists in an increase in the 
heart muscle combined with an increase in the capacity of its 
chambers. 

Etiology. — Hypertrophy of the heart occurs in all condi- 
tions in which great muscular effort is required, so that the 
heart must perform more work. 

The factors giving rise to hypertrophy of the heart may be 
divided into — 

First. — Causes relating to the blood-vessels. 

Second. — Causes relating to the heart. 

Third. — Causes relating to the nervous system. 

Fourth. — Toxic causes. 

Causes Relating to the Blood=vessels. — If interference 
occurs with the flow of blood through the small arteries, the 
blood pressure rises, and cardiac contractions are increased in 
force to overcome the obstacle. This may be due to in- 



HYPERTROPHY OF THE HEART. 345 

elasticity and loss of contractile power in the arteries, to nar-* 
rowing of their caliber, or to actual obliteration, thus bring- 
ing about a marked increase in peripheral resistance. These 
causes lead to hypertrophy of the left ventricle. When they 
occur in the pulmonary circuit the right ventricle becomes 
hypertrophied. 

General arterial sclerosis is the chief factor in causing in- 
creased peripheral resistance. In this condition the walls of 
the small arteries become stiff and rigid and are unable to 
dilate. When the vascular system is filled, the blood pressure 
necessarily rises, and the ventricles make greater efforts to 
overcome the resistance, the aortic cusps close tightly, and 
hypertrophy results. This is common in gout and chronic 
interstitial nephritis. Extensive atheromatous change in the 
larger arteries also leads to hypertrophy. 

Emphysema and chronic interstitial pneumonia are the 
principal causes of hypertrophy of the right ventricle. A 
pleural effusion, by compressing the capillaries, may cause 
the pulmonary capillaries to become obliterated, and the in- 
creased pressure may arise from this cause. Aneurysm also 
causes hypertrophy. 

Causes Relating to the Heart. — Aortic regurgitation and 
aortic stenosis produce great hypertrophy of the left ventricle, 
for reasons which have already been explained. (See Aortic 
Regurgitation and Stenosis.) Mitral regurgitation also gives 
rise to hypertrophy of the left ventricle on account of the 
increased amount of blood thrown into the ventricle at the 
auricular systole. Stenosis of the mitral orifice gives rise to 
hypertrophy of the left auricle. Hypertrophy of the right 
ventricle is often due to mitral disease. These lesions increase 
the blood pressure in the pulmonary vessels. 

Active physical exertion continued through a long period 
of time produces hypertrophy. It is commonly met with in 
athletes, soldiers, and laborers whose vocations require pro- 
longed physical effort. 

Causes Relating to the Nervous System. — Cardiac hyper- 
trophy is met with in those addicted to excessive venery, and 
is a common occurrence in exophthalmic goiter. 

Toxic Causes. — The principal among these are alcohol, 
coffee, tea, tobacco, and lead. 

Pathology. — The heart is increased in size so that in ex- 
treme cases it may weigh 600 grams or even more. In 
hypertrophy of the left side the heart increases in length, 



34^ DISEASES OF THE CIRCULATION. 

whereas in hypertrophy of the right side the apex is more 
rounded and the transverse measurement is increased. 

Microscopically, the fibers are increased in numbers, and 
are thickened, the nuclei being swollen. Some degree of 
myocarditis is almost always associated. 

A certain amount of dilatation is usually found with it. 

Symptoms. — Among the early symptoms of hypertrophy 
of the heart is shortness of breath upon exertion. There 
may be flushing of the face, noises in the ears, and flashes of 
light before the eyes. The carotids may throb forcibly. 
There are disagreeable sensations in the epigastrium after 
taking a full meal. Pain does not occur, as a rule. Head- 
ache and vertigo are common, and the patient becomes con- 
scious of the action of the heart especially upon retiring to bed 
and resting upon the pillow. The pulse is full and strong and 
of high tension. These symptoms may all continue until 
changes take place in the myocardium and dilatation occurs. 
Cerebral hemorrhage from rupture of one of the smaller 
arteries of the brain may be a complication. 

Physical Signs. — It is impossible to make a diagnosis of 
hypertrophy of the heart without a physical examination. 

Inspection. — On inspection there may be bulging in the 
precordial region. This, however, is not frequent, and is 
most often the result of previous disease, such as pericarditis. 
In children, bulging in the precordium is of frequent occurrence 
in hypertrophy of the heart. The apex -beat is displaced 
downward, and may be found as low as the eighth intercostal 
space in the anterior axillary line. Displacement to the right 
may also be noted. The impulse is heaving and powerful in 
character. Violent throbbing of the superficial arteries com- 
monly shows itself. 

Palpation — Palpation confirms inspection. 

Percussion — Percussion of the heart is very unsatisfactory 
and yields questionable results. 

Auscultation — Auscultation gives a booming, prolonged, 
dull first sound. If the tension be high, the second sound 
will also be sharp and ringing. Occasionally there may be 
reduplication of the second sound from absence of synchronous 
closure of the semilunar valves. 

Diagnosis. — The diagnosis rests upon the displacement of 
the apex-beat usually downward and to the left, the heaving, 
forcible impulse, with the symptoms of headache, vertigo, 
gastro -intestinal disturbances, etc. 



DILATATION OF THE HEART. 347 

Prognosis. — The prognosis in uncomplicated cases may be 
favorable, the danger being due to subsequent dilatation. With 
proper treatment, chiefly regulation of the habits, excessive 
myocardial changes may be warded off for years. The 
younger the patient the more likely it is that hypertrophy may 
be arrested. 

Treatment. — The treatment consists, wherever possible, in 
the removal of the cause. The bodily functions should be 
carefully looked after ; the patient's diet must be regulated, 
overeating forbidden, alcohol, coffee, and tea prohibited, and 
proper rest prescribed. Drugs, as a rule, are not indicated ; 
aconite in small doses is perhaps the most valuable in certain 
cases. 

DILATATION OF THE HEART. 

Definition. — Cardiac dilatation, from a pathologic stand- 
point, may be divided into simple dilatation and dilatation with 
hypertrophy. 

Simple dilatation consists in an increase in the size of 
the cavity accompanied by thinning of the heart-wall. 

Dilatation with hypertrophy consists in an increase in the 
size of the cavity with increase in the heart muscle. 

Simple dilatation is always primary and acute; dilatation 
with hypertrophy, secondary and chronic. 

ACUTE OR SIMPLE DILATATION. 

Definition. — Acute dilatation is a sudden overdistention of a 
cavity or cavities of the heart, characterized by serious and 
often fatal symptoms. 

Etiology. — Any condition which produces increased intra- 
cardiac pressure may produce dilatation. This may result 
from severe muscular exercise, forced marches, mountain- 
climbing, etc. Under such circumstances the right ventricle 
will suffer most. 

After the rupture of a cardiac valve, acute dilatation may 
take place. The infectious diseases predispose to this condi- 
tion in causing degenerative changes in the heart-wall. 

Sudden death sometimes occurs in diphtheria, enteric 
fever, etc., where the patient sits up in bed. This is caused by 
the abrupt distention of the ventricles, followed by paralysis. 
In croupous pneumonia, overdistention of the right heart 
takes place and often causes death. 



34-8 DISEASES OF THE CIRCULATION. 

Thrombosis of the pulmonary artery has led to the same 
result. Sudden plunging into cold water is sometimes followed 
by acute dilatation. 

Pathology. — The cavity affected is distended with dark, 
partly coagulated blood, and its walls thinned. The right 
ventricle is more often affected than the left ; also the right 
auricles more often than the left. If obstruction occurs in 
the systemic vessels, the left ventricle suffers most. 

Symptoms. — The symptoms come on abruptly. Dyspnea 
is a marked symptom. There may be pain in the precordial 
region ; vertigo or dizziness. Nausea and vomiting are 
not always present, but they frequently appear. Pallor of 
the face with cyanosis, especially of the lips, is characteristic. 
Flashes of light appear before the eyes, and the patient may 
become unconscious. These symptoms may be transitory, or 
increase in severity so that a fatal result may ensue. 

Physical Signs. — A feeble, diffused impulse, with an in- 
creased area of cardiac dullness, with weak, rapid, indistinct 
heart-sounds, are the common physical signs. 

Diagnosis. — This depends upon the occurrence of the symp- 
toms and physical signs just described. 

Prognosis. — If death does not occur at once, the sub- 
sequent changes may lead to it. If the dilatation be mod- 
erate, and compensatory hypertrophy take place, recovery 
may follow. 

Treatment. — Absolute rest in bed is important. Cardiac 
stimulants, such as alcohol, the nitrites, especially nitro- 
glycerin, and hypodermics of strychnin are useful. An 
ice-bag over the heart may give relief. If improvement 
takes place, digitalis may be given with benefit. In acute 
dilatation venesection is of great value. During conva- 
lescence tonics should be prescribed. 



CHRONIC DILATATION. 

Etiology. — The exciting cause is increased intracardiac 
pressure. When this is gradual, as in valvular lesions of the 
heart, the dilatation is slow, and is usually compensated for by 
hypertrophy of the affected cavity. The coronary arteries 
sooner or later show atheromatous changes in their walls, so 
that nutrition of the myocardium becomes impaired. 

Pathology. — More than one cavity is usually affected, and 
the heart is larger than normal. The cavities may contain 



DILATATION OF THE HEART. 349 

uncoagulated blood, and the auricles large clots. The auriculo- 
ventricular ring is stretched on both sides, and the tips of 
the valve segments do not come together. This may in rare 
cases be prevented by calcification at the bases of the mitral 
valves. 

The papillary muscles and chordae tendinae are shortened 
so that with the ventricular systole the relative incompe- 
tence is increased. The wall of the dilated chamber is pale, 
and the coronary arteries are diseased and may be partly oc- 
cluded. 

Congestion of the lungs, liver, kidneys, spleen, and intes- 
tines accompany cases of long standing. 

Symptoms.— As dilatation is slow and progressive, the 
symptoms may remain latent for a long time. The first signs 
may be due to imperfect aeration of the blood in the lungs, 
the brain receiving a deficient amount of arterial blood, the 
abdominal viscera becoming congested and their functions 
perverted. The stagnation of the blood current permits 
transudation of the liquid elements from the blood, and dropsy 
takes place. Cardiac palpitation is one of the earliest symp- 
toms. It is often accompanied by pain and distress in the 
precordial area. The rhythm of the heart becomes disturbed, 
and the patient becomes conscious of it. The pulse is rapid, 
irregular, and often intermittent. Dyspnea is a prominent 
symptom. 

Respiration is hurried and shallow, and often accompanied 
by cough and expectoration, which may contain blood. From 
changes which take place in the stomach and intestines dys- 
peptic symptoms occur. 

The kidneys fail to excrete the normal amount of urine, 
which is of a darker color and of high specific gravity, contain- 
ing albumin, often red blood-cells, and casts. The edema which 
accompanies this condition begins in the feet, and may extend 
over the entire body until there is a condition of anasarca. 
The serous cavities are filled with fluid ; this is especially 
likely to happen toward the close of life. 

Physical Signs. — Inspection. — The apex-beat is feeble, 
displaced toward the right, with a diffused impulse, which 
often presents a wavy character. 

Palpation. — Palpation confirms inspection, and the impulse 
may be so feeble that it can not be felt. 

Percussion. — Percussion may show an increase of cardiac 
dullness laterally, especially to the right. 



350 DISEASES OF THE CIRCULATION. 

Auscultation. — The first sound of the heart is feeble, due 
to the loss of its muscular element, but the valvular sound 
may be pronounced. The first sound is short, sharp, and 
feeble, and resembles the normal second sound. It may be 
intermittent. Reduplication of the first sound may occur, 
due to a want of synchronism of the left and right ventricle. 

Murmurs may be present, due to stretching of the auriculo- 
ventricular ring, or if murmurs were present previous to the 
dilatation they lose their intensity or may disappear, this being 
the result of the weakened heart muscle. 

Diagnosis. — The diagnosis depends upon the feebleness of 
the impulse, its wavy character, the feeble first sound, which 
is often reduplicated, and the symptoms just enumerated, with 
signs of edema and perhaps anasarca. 

Prognosis. — The prognosis is unfavorable. 

Treatment. — The treatment should be directed to the 
maintenance of the nutrition of the body and the control of 
the cardiac action. Food must be given in small quantities, 
at frequent intervals, and it is important that it be highly 
nutritious. Fatigue should be avoided. It is necessary for 
the functions of the body to be kept in normal working order. 
The kidney may be stimulated by diuretics, and a mild laxa- 
tive be given for the bowels. Digitalis and strychnin are the 
best drugs for this condition. Basham's mixture is often of 
use. 

DISEASES OF THE MYOCARDIUM. 

FATTY INFILTRATION. 

Synonyms. — Fatty overgrowth ; cor adiposum. 

This is a condition in which fat is deposited under the vis- 
ceral layer of the pericardium, especially marked about the 
auriculoventricular groove. It also deposits itself between the 
muscle-fibers, causing some atrophy, and occasionally fatty 
degeneration may accompany the condition. 

The cause of fatty infiltration may be said to be seden- 
tary habits, overeating, and hereditary. Most commonly it is 
encountered in obesity, the heart being one of the organs 
which is affected in this general process. 

Symptoms and Signs. — The symptoms are rarely sub- 
jective, but on examination it will be found that the apex-beat 
is very faint, or invisible, and auscultation reveals a weak first 
sound and a relatively distant second sound. This results 



DISEASES OF THE MYOCARDIUM. 351 

from the increase of fat, which interferes with the heart's 
motion. It has been said that fatal termination from impair- 
ment of the contractile power has resulted. 

PARENCHYMATOUS DEGENERATION. 

This condition is usually associated with infectious diseases 
and fevers. It is also a forerunner of fatty degeneration. The 
heart, as a result of this condition, becomes softer, paler, and 
more friable. Microscopic examination reveals swelling of 
the heart muscle, and a granular precipitate. 

FATTY DEGENERATION. 

Etiology. — This may be either partial or general. 

It may result from prolonged infectious diseases, following 
parenchymatous degeneration of the myocardium, and often 
accompanying this condition. Anemic states, particularly pro- 
gressive pernicious anemia, cause the affection. Poisons, such 
as phosphorus, antimony, and arsenic, produce it. 

Interference with the circulation of the coronary arteries, 
due to atheroma, thrombosis, and embolism, usually causes 
partial fatty degeneration. 

Pathology. — The heart, as a rule, is smaller than normal. 
Its consistency is lax and flabby, and of a yellowish brown 
color, certain areas being lighter, of a yellowish-gray color. 
This discoloration (brindled, striated, or tabby-cat appearance) 
is most marked about the columnar carneas and papillary 
muscles, but it may be quite extensive. The left ventricle 
is effected more often than the right. The heart muscle is 
found to be anemic. 

Microscopic examination reveals small fatty droplets in the 
heart muscle, many of the nuclei being completely obliterated 
and replaced by fat globules. These globules are small, and 
scattered throughout the muscle-fiber. This fatty process 
is more marked in certain areas than in others, giving rise to 
the brindled or striated appearance, the lighter areas corre- 
sponding to the fatty degeneration. 

Fatty degeneration of other organs frequently accompanies 
the lesion of the heart, especially when it is due to some 
general malnutrition. 

Symptoms and Signs. — Unless the degenerative process 
reaches a certain grade, the diagnosis is impossible. Marked 
symptoms and signs only occur in advanced disease. The 



352 DISEASES OF THE CIRCULATION. 

most important of these changes consists in passive dila- 
tation of the ventricles so thajt the apex-beat becomes weak, 
diffuse, and even entirely absent. The heart-sounds are 
correspondingly weak, but clear, and in a high grade of dila^ 
tation may be accompanied by a systolic murmur. Enlarge- 
ment of the liver, due to passive congestion, and albuminuria, 
may occur in consequence. The radial pulse, on account 
of the insufficient work performed by the heart muscle, is 
weak, and in the majority of cases slow, and twenty beats a 
minute have been recorded. In consequence of this slowing 
of the heart's action syncope and even apoplexy may occur. 

Cheyne-Stokes respiration takes place in grave cases. 
Among the symptoms may be mentioned dyspnea, especially 
upon exertion, attacks of asthma (cardiac), palpitation, angina 
pectoris, and constipation. In the eye, an arcus senilis may 
be seen. 

Diagnosis. — The diagnosis depends upon the history of 
the case, preceding disease, especially occurring in acute infec- 
tions in young persons. The slow pulse, the signs of passive 
dilatation of the ventricles with accompanying symptoms. 

Prognosis. — The prognosis is unfavorable as to cure, 
although the patient may live many years. 

Treatment. — The treatment consists in careful regulation of 
the diet, attention to the functions of the body, and the syste- 
matic use of such drugs as alcohol and strychnin. Iodid 
of potassium and arsenic are recommended by many au- 
thorities. 

ACUTE MYOCARDITIS. 

This is an inflammation of the heart muscle. It usually 
results from an infected embolus in the course of pyemia. 
It sometimes arises during diphtheria, typhoid fever, gonor- 
rhea, rheumatic fever, anthrax, and scarlet fever, or it may 
result by extension from acute endocarditis and pericarditis. 

Acute myocarditis usually terminates in abscess formation. 
However, there may be simply an infiltration of round cells 
and leukocytes with accompanying blood-vessel changes. 
The muscle-fibers around this area usually show some degree 
of parenchymatous degeneration. 

The wall of the left ventricle is generally the seat of the 
condition. The right side is rarely affected. Abscesses, 
when multiple, are usually pyemic in origin. 

The condition may terminate in rupture or aneurysm. 



DISEASES OF THE MYOCARDIUM. 353 

CHRONIC INTERSTITIAL MYOCARDITIS. 

Synonyms. — Chronic myocarditis ; fibroid heart. 

Etiology. — Traumatism, injuries, cold, overexertion, alco- 
hol, tobacco, lead-poisoning, gout, diabetes mellitus, or the in- 
fectious diseases, such as malaria, syphilis, and rheumatic fever, 
may give rise to this condition. Changes in the coronary arte- 
ries are causative factors. Chronic interstitial nephritis fre- 
quently accompanies this condition, and the general senile 
changes are responsible, commonly called senile myocarditis. 

Occasionally the acute condition may become chronic and 
so give rise to the disease. It is more common in men than 
in women, and occurs more frequently after the fortieth year. 

Pathology. — This is essentially a cirrhosis of the heart. 
It frequently involves the wall of the left ventricle, especially 
about the apex. Hypertrophy is often associated. The 
fibrous connective tissue surrounds the bundles of heart mus- 
cle, causing atrophy. Sclerosis of the coronary arteries 
frequently accompanies this condition, and sometimes occlu- 
sion of these vessels is met with. Aneurysm and dilatation 
of the heart may develop as a result of chronic interstitial 
myocarditis. Chronic endocarditis and pericarditis are often 
associated diseases. 

Symptoms and Signs. — These may be entirely latent and 
the condition in mild grades not likely to be recognized. In 
the advanced stages pain in the precordium, especially upon 
slight exertion, becomes prominent. It radiates and shoots 
down the left arm, and tingling may take place in the fingers. 
Shortness of breath is a prominent symptom. 

The apex-beat is weak and diffused. The pulse is feeble 
and often intermittent. Marked arrhythmia occurs. Occa- 
sionally sudden death takes place and the autopsy may fail 
to reveal the cause. Constipation and gastric disturbances 
are prominent. If there be passive congestion, cyanosis and 
edema of the skin occur. 

AMYLOID DISEASE. 

Amyloid or wax-like disease of the myocardium results 
from chronic malaria, syphilis, long continued suppuration, — 
especially of bone, — and lead-poisoning. By some this is con- 
sidered to be a degeneration, by others an infiltration. 

The amyloid material deposits itself in the interstitial 
tissue and around the blood-vessels. It is usually accom- 
23 



354 DISEASES OF THE CIRCULATION. 

panied by similar changes in other organs, such as the 
kidneys, liver, and spleen, and its presence can only be sus- 
pected by the disease existing in other organs. 

Diagnosis of Myocarditis in General. — The diagnosis of 
myocarditis depends upon a recognition of the cause, the age 
of the patient, the slow intermittent arrhythmical pulse, with 
the signs of passive congestion. 

Prognosis. — The prognosis as to cure is unfavorable. 
With proper care and systematic treatment the patient may 
live for many years. 

Treatment. — The treatment consists in proper hygiene, 
attention to the excretions, easily digested food, and the use 
of alcohol, strychnin, iodid of potassium, or arsenic in proper 
doses. Digitalis in this condition is contraindicated. The 
Nauheim bath treatment is valuable in this disease. 



ANEURYSM OF THE HEART, 

Etiology.— Aneurysm of the heart most frequently affects 
the wall of the left ventricle, sometimes the septum between 
the ventricles, and rarely the right side. This condition is 
very uncommon. It results from lesions of the muscular 
fibers of the heart, such as fatty degeneration, acute suppura- 
tive myocarditis, and chronic fibrous myocarditis. 

Any effort requiring great muscular strain by causing 
decreased resistance, with an increase in the vascular tension, 
may give rise to aneurysm. Age is an important factor, this 
condition usually occurring after forty. It is more frequent in 
men than in women. 

Symptoms and Signs. — The symptoms in this disease are 
not characteristic. 

The diagnosis must be made by exclusion rather than by 
direct symptoms and signs. Pain in the precordium is usually 
present. Murmurs, if they occur, are not distinctive, and are 
usually dependent upon some other cause. If the aneurysm 
is very large and situated anteriorly, bulging of the chest wall 
with pulsation is present. It may terminate in rupture. 
Pericarditis is almost invariably associated with aneurysm of 
the heart. 

Cardiac aneurysm can not be positively diagnosticated. 

Prognosis. — The prognosis is hopeless. 

Treatment. — The treatment consists in relieving the pain 
by the use of opiates. 



NEW GROWTHS AND PARASITES. 355 

RUPTURE OF THE HEART* 

Rupture of the heart usually results from over-exertion, the 
heart muscle being, as a rule, previously diseased, either 
from fatty infiltration, or more frequently from fatty degener- 
ation, acute suppurative myocarditis, or previous aneurysmal 
dilatation. The rupture may cause a sudden gush of blood 
into the pericardial sac, or a slow leakage may continue for a 
long time. 

Disease of the valves, especially of the aortic valves, on 
account of great hypertrophy of the left ventricle, may give 
rise to rupture. 

Rupture most frequently occurs in the anterior wall of the 
left ventricle. Disease of the coronary arteries is often the 
cause of the diseased myocardium. Softening of the heart 
muscles, due to new growths and echinococci, has caused 
rupture of the heart. 

Symptoms and Signs. — If the disease comes on gradu- 
ally, with slow leakage, the symptoms are not diagnostic. 
There may be marked dyspnea, with palpitation and pain, 
partial suppression of the urine, or even anuria due to the 
lowering of blood pressure. Where the rupture takes place 
suddenly, great pain and precordial distress occur, rapidly 
followed by death. 

The physical signs in either condition may show a weak or 
absent apex-beat. The sounds are feeble and irregular. An 
increased area of cardiac dullness, due to the effusion of blood 
into the pericardial sac, may occur. 

Prognosis. — The prognosis is absolutely unfavorable. 

Treatment. — The treatment consists in applying ice-bags 
to the heart, and the liberal administration of opium. 

NEW GROWTHS AND PARASITES* 

All malignant growths, carcinoma, &S well as sarcoma, 
have been found in the heart. When they are secondary, they 
occur particularly in the pericardium and endocardium rather 
than in the muscular substance. New growths are extremely 
rare. Of nonmalignant growths there are fibroma, lymphoma, 
and myoma. Hydatid disease of the heart has been noted. 

Diagnosis. — A diagnosis is impossible except, perhaps, by 
exclusion. 

Symptoms. — The symptoms of pericarditis are almost 
invariably present. 



35^ DISEASES OF THE CIRCULATION. 

Prognosis. — The prognosis in any condition is unfavorable. 
Treatment. — The treatment is purely symptomatic. 



NEUROSES OF THE HEART. 

By a neurosis is meant a disturbance in action, or function, 
independent of an organic lesion. 

ARRHYTHMIA. 

Definition. — An irregular rhythm of the heart's action. 

Etiology. — This may be due to either direct, reflex, or 
toxic causes, or to any combination of these. 

Direct Causes. — Any disturbance of the pneumogastric 
nerve or of a brain lesion would constitute a direct cause, 
such as apoplexy, brain tumor, abscess of the brain, pressure 
upon a nerve trunk by enlarged glands or a neoplasm. 

It often occurs in endo- and pericarditis, myocarditis, and 
arteriosclerosis. Alterations in the blood itself — anemia, 
chlorosis, etc. — may give rise to the condition. 

A distention of the stomach by gases, causing pressure up- 
ward, may produce arrhythmia. In some forms of Bright's 
disease it commonly occurs. 

Reflex Causes. — The condition may be due to an organ in 
the body away from the heart, especially found in disease of 
the abdominal organs. It also arises from shock, trauma, and 
from pain. 

Toxic Causes. — The infectious diseases ; digitalis, mus- 
carin, coffee, tea, tobacco, and alcohol. 

Symptoms. — As the name implies, the principal symptoms 
consist in irregularity in the heart's action. Intermissions, 
with difference in the volume of the pulse, take place. The 
heart-beats may occur at long or short intervals, and may be 
bounding or feeble. 

Prognosis. — This depends upon the cause and the ability 
to remove the productive factor. 

Treatment. — The treatment is symptomatic. 

PALPITATION. 

By palpitation is meant heart -beating which is perceptible 
and annoying to the patient. It may be due to causes within 
the heart itself as organic disease, and exophthalmic goiter. 

Reflex Causes. — Reflex causes may give rise to it — disease 



NEUROSES OF THE HEART. 357 

of the stomach, disease of the genito-urinary apparatus, and 
sexual excesses. 

Toxic causes consist in the abuse of alcohol, tobacco, tea, 
and coffee. Gout and anemia are productive factors, and the 
condition occurs in inanition and marasmus. 

Symptoms. — Perceptible heart's action, which varies in 
intensity, is the important factor. The attacks depend on 
slight causes, and may occur at night, awakening the patient 
from sound sleep. Associated symptoms may be pallor of 
the face, with cold, clammy sweat, sighing respirations ; also 
vertigo, tremor, cyanosis, and syncope may occur. The 
attack may last from a few minutes to the greater part of the 
day. 

Prognosis depends upon the cause ; usually favorable. 

Treatment. — Treatment is symptomatic. Rest in the 
recumbent posture is important. 

IRRITABLE HEART. 

Two varieties of this condition exist : (i) A form occurring 
in young persons ; (2) the so-called soldier's heart. 

Etiology. — Overeating, tobacco, alcohol, hard study, and 
nonsystematic exercise are potent causes in its development. 
In soldiers it is often due to forced marches, especially in 
those persons not accustomed to taking exercise. The male 
sex is oftener affected than the female. 

Symptoms and Signs. — These consist in uneasiness about 
the heart, irregularity of the cardiac action, occasionally slow, 
then rapid beats, and perhaps slight pain. The first sound is 
often muffled (" murmurish "). There are no distinct signs 
of hypertrophy, although if the condition be prolonged this 
organic change may occur. There are disturbances of diges- 
tion, eructation of gases, and constipation. The person is 
irritable (nervous), and in great anxiety in regard to the con- 
dition of his heart, the irregularity of which is apparent to 
him. 

Prognosis. — With proper care, the prognosis is favorable, 
although the condition may lead to organic change. 

Treatment. — Regulation of the habits and avoidance of 
tobacco, alcohol, tea, and coffee. Muscular exertion must be 
systematic and guarded. Change of scene and pleasant sur- 
roundings are often beneficial. Small doses of the bromids 
are useful, but digitalis should be avoided unless organic 
change (dilatation) takes place. 



35° DISEASES OF THE CIRCULATION. 



TACHYCARDIA, 



By this is meant increased frequency of the heart's action. 
The condition may be permanent, periodic, or paroxysmal. 
It is permanent in exophthalmic goiter. In the fevers and 
during convalescence from fevers, from great and, rapid blood 
loss, and in anemia it appears periodically. It is spoken of as 
paroxysmal when it occurs from fright or some nervous irri- 
tation. 

Symptoms. — The symptoms consist in an increased fre- 
quency of the pulse, occurring in paroxysms, which may be 
unprovoked, or excited by a trivial cause. The pulse rate may 
be increased to 140 or as high as 200 beats per minute, rarely 
more. Paroxysmal tachycardia usually sets in suddenly in 
persons who are apparently in good health. The heart shows 
no evidence of organic lesion in the paroxysmal cases. 

Prognosis. — The prognosis is favorable as to life, but the 
condition is extremely obstinate, and usually continues until 
there follows degeneration of the heart. 

Treatment. — The treatment should consist in the relief of 
the attack. The use of drugs is exceedingly unsatisfactory. 
Rest, in the recumbent posture, is perhaps the most useful agent 
in procuring relief. Hydrotherapy is useful in many instances. 

BRADYCARDIA OR BRACHYCARDIA. 

Bradycardia is the slow action of the heart. The normal 
pulse range is from 60 to 80 per minute, but in bradycardia 
the pulse may fall to 40, 30, or even less per minute. As in 
the opposite condition (tachycardia), bradycardia is permanent, 
temporary, or paroxysmal. 

It is usually permanent in organic disease of the brain. 

Temporary bradycardia is much more common, occurring 
in some of the infectious fevers, especially yellow fever, and 
in puerperal fever. It may occasionally occur in diphtheria. 
The accumulation of bile in the blood slows the pulse. The 
absorption of toxins in the alimentary canal may have a similar 
effect. 

Paroxysmal bradycardia sets in abruptly in persons seem- 
ingly in good health, and without apparent cause. 

Symptoms. — The symptoms consist in a slowing of the 
pulse rate. If the pulse becomes markedly slow, the patient 
may lapse into a semicomatose condition, with a pallid or 
flushed face, and with cool or hot extremities. 



NEUROSES OF THE HEART. 359 

Prognosis. — The disease is commonly regarded serious, as 
the principal causes of the affection are diseases of the brain 
and spinal cord- 
Treatment. — Stimulants, such as digitalis and nitroglycerin, 
are not indicated so long as the heart supplies the wants of 
the body. Oil of camphor, hypodermically, is of use in this 
affection. Strychnin should also be given as a general heart 
tonic. 

ANGINA PECTORIS. 

Definition. — Angina pectoris is a neurosis of the heart, 
commonly due to sclerosis or atheroma of the coronary 
arteries or myocardial disease, characterized by severe pain in 
the region of the heart, radiating to the left shoulder and left 
arm, and other symptoms. 

Etiology. — Occlusion of the coronary arteries is an impor- 
tant factor, as is also sclerosis. Predisposing causes are age 
and sex ; the disease occurs after the middle period of life, and 
in an overwhelming number of cases in the male sex. 

Heredity, in so far as it gives rise to sclerosis, may have 
some slight predisposition. Syphilis is an important predis- 
posing factor. Sedentary habits, and lack of proper exercise, 
have also been noted as predisposing causes. 

Pseudo-angina Pectoris. — Pseudo-angina pectoris occurs 
particularly in younger subjects, and in women in connection 
with hysteria and neurasthenia. 

Symptoms. — The attack takes place suddenly. The patient, 
probably without prodromes, is seized with severe lancinating 
pain in the precordial region, which radiates to the left shoulder 
and down the left arm, so that the arm and fingers are fre- 
quently numb. The attack may be so severe as to cause 
death at once. The patient describes the sensation as a feel- 
ing of compression of the heart, and as though it were im- 
possible for him to draw his breath. The heart's action 
during the attack is variable ; the circulation may be entirely 
unaffected, or there may be palpitation and arrhythmia. The 
pulse may be decreased or increased in frequency. The disease 
occurs commonly in combination with aortic affections, espe- 
cially stenosis of the aortic valves. It is often found in chronic 
myocarditis. 

The duration of the attack varies from half a minute to 
several hours. The intervals between the attacks also vary. 
Exceptionally, the patient may have but one attack, from 



360 DISEASES OF THE CIRCULATION. 

which he may recover. It is, however, usual for the patient 
to have several, the disease proving fatal in one of them. 

Symptoms of Pseudo-angina Pectoris. — The disease oc- 
curs with pain in the precordium in young persons, particu- 
larly women, in association with hysteria and neurasthenia. 
The pain may radiate down the left arm. During the attack 
the patient may pass a large quantity of urine, or there may 
be eructation of gas. 

Diagnosis. — The diagnosis is easy as a rule ; the excru- 
ciating pain, the anxiety of the patient, the signs of arterio- 
sclerosis, and the occurrence in the male sex, all point 
prominently to angina pectoris. 

In pseudo-angina pectoris the accompanying phenomena of 
hysteria or neurasthenia are important diagnostic points. 

Differential Diagnosis. — 

Angina Pectoris. Pseudo-angina Pectoris. 

Male sex after forty years of age. Young females of neurotic tempera- 
ment. 

Some disease of heart or blood vessels. No organic disease of the heart. 

Attacks not so frequent and more pro- Attacks more frequent, and briefer in 

longed. duration. 

Often loss of consciousness. Rarely loss of consciousness. 

Often fatal. Rarely fatal. 

Prognosis. — The prognosis in true angina is always unfav- 
orable. Cure frequently takes place in pseudo-angina. 

Treatment. — The treatment must be divided into two 
parts : the treatment of the attack, and the care of the patient 
in the interval. In the attack, hypodermics of morphia are 
necessary. Inhalation of amyl nitrite, or the employment of 
nitroglycerin in full doses may prove beneficial. 

In the interval between the attacks the patient must lead a 
quiet life. The functions of the body should be well looked 
after, and doses of nitrite of sodium with strychnin are of use. 

Pseudo-angina may be relieved by Hoffmann's anodyne, or 
applications of hot or cold water over the heart. 



ARTERITIS. 361 



DISEASES OF THE ARTERIES. 



INFILTRATIONS AND DEGENERATIONS, 

Calcareous Infiltration. — Calcareous infiltration frequently 
affects the arteries, either in the course of atheromatous 
changes, or the artery may simply be impregnated with lime- 
salts without any foregoing pathologic change, being con- 
verted into a stone-like tube. This infiltration also occurs in 
the final organization of thrombi. 

Amyloid Disease. — Amyloid infiltration of the arteries 
results from syphilis, chronic malaria, tuberculosis, suppura- 
tion — especially that of bone — and chronic lead-poisoning. 
The smaller (medium sized) arteries are almost without ex- 
ception the ones which are affected by this infiltration. This 
may lead to a weakening of the arterial wall, and aneurysm 
may result. Amyloid infiltration in the internal organs usually 
accompanies this condition. 

Fatty Degeneration. — Simple fatty degeneration of the 
intima usually occurs in individuals beyond middle life, and 
Virchow has described a similar condition occurring in chlo- 
rotic girls. Fatty degeneration, however, is usually one of the 
stages in atheroma. 

Hyaline Degeneration. — Hyaline degeneration may also 
attack the arteries, commonly involving the intima. 



ARTERITIS, OR INFLAMMATION OF THE 
ARTERIES* 

ACUTE ARTERITIS. 

This condition usually results from some infective process. 
It is frequently encountered in pyemia, sometimes in ulcera- 
tive endocarditis and enteric fever. It may affect any of the 
arteries. The changes noted are distention of the vasa 
vasorum, the intima becomes roughened, and there is an in- 
flammatory infiltration into one or more coats of the arteries 
which may go on to the formation of pus, or in some in- 
stances an aneurysm develops. Acute aortitis is rare, being 
a condition similar to ulcerative endocarditis. Thrombosis 
may result from roughening of the intima. 



362 DISEASES OF THE CIRCULATION. 

Micro-organisms may be found upon the surface of the 
projection or vegetation, and in the inflammatory area in the 
coats of the arteries. 

Symptoms. — Acute arteritis may occur during the process 
of a primary lesion or during convalescence. The important 
symptom is spontaneous, localized pain in the region affected, 
most frequently a limb, exaggerated by movement and by 
pressure. Upon the occurrence of thrombosis a painful cord 
may be felt in the affected area. The pulse is obliterated, 
there is numbness and tingling with anesthesia, coldness of 
the skin, and swelling. The local temperature is lowered, and 
gangrene may follow. 

ARTERIOSCLEROSIS. 

Synonyms. — Arteriocapillary fibrosis ; Gull and Sutton's 
disease. 

Definition. — A sclerosis of the arteries, affecting usually 
the intima, but the adventitia and media may be involved. 
This may be local or general. 

Etiology. — Arteriosclerosis is more common in the male 
than in the female sex. 

This condition usually results from advancing age, but 
the rule has many exceptions, as the young are frequently 
attacked. It is a well-known saying that, " A man is as old 
as his arteries." 

Heredity seems to play an important part in the causation, 
as some families show a distinct tendency to arteriosclerosis 
early in life. Improper living, sedentary occupations, over- 
eating, overwork, occupations which give rise to severe mus- 
cular exertion, and syphilis are all important factors in the 
causation of this disease. Persons suffering from gout show a 
marked tendency to arteriosclerosis. Alcohol and chronic 
lead-poisoning are also important causes. 

Chronic interstitial nephritis gives rise to this condition ; 
however, kidney disease may be secondary to arteriosclerosis, 
and again, both conditions, no doubt, often occur simul- 
taneously from a common cause. 

Pathology. — Arteriosclerosis may be diffuse, affecting many 
of the small arteries of the body, those of the brain, of the 
heart, and of the extremities. The arteries of the lungs are 
less commonly involved. Again, the sclerosis may be con- 
fined to the larger arteries, such as the aorta. 



ARTERIOSCLEROSIS. 363 

i. Atheromatous Arteritis. 

This disease is primarily one of the intima. Early there is 
a milky opacity of this coat, and a thickening takes place in 
this membrane. A yellowish spot may next appear in the 
thickened area, which is the result of fatty degeneration. 
This fat may be carried away by the blood stream, leaving an 
ulceration, or the fatty patch may be converted into a calca- 
reous plate. If the former result, the artery is predisposed 
to aneurysmal dilatation. In the latter event, emboli may be 
thrown into the circulation, providing the atheromatous plates 
are dislodged. This atheromatous change most frequently 
involves the aorta, but the iliacs, femorals, and arteries of the 
limbs and the cerebrals are often involved. 

Microscopically, the thickening simply consists in the 
formation of fibrous connective tissue. As a result of this, 
the elasticity of the vessel becomes impaired and may dilate 
and form an aneurysm. 

2. Arteritis Obliterans. 

This condition, as a rule, occurs from syphilis. Occasion- 
ally, this change has been found in the cirrhotic kidney, 
fibroid lung, and in blood-vessels after ligation. The intima 
shows great thickening as a result of fibrous connective-tissue 
formation. The elastic coat and the muscular coat show little 
change, and the adventitia may in some instances be thickened. 
In consequence of this, the lumen of the artery becomes 
diminished, and in some instances completely obliterated, 
often leading to gangrene of the parts supplied. The intima 
does not show a tendency to fatty degeneration, so that it 
does not predispose to aneurysm, and the condition is usu- 
ally associated with other signs of constitutional syphilis, and 
affects most frequently the small arteries. 

3. Diffuse Arteriosclerosis. 

This condition is wide-spread, occurring frequently during 
middle life. The intima shows marked thickening, and the 
disease affects, more or less, the aorta and its branches. 

As a consequence of sclerosis, the vessel-walls become 
inelastic, the onward flow of the blood is somewhat prevented, 
as the resistance is increased, and sooner or later the left ven- 
tricle becomes hypertrophied. This is especially so when it 
is associated with chronic interstitial nephritis. The arterial 
tension becomes high, and the diseased arteries are liable to 
aneurysmal dilatation. As a result of roughening of the 
intima, thrombosis not infrequently occurs. 



364 DISEASES OF THE CIRCULATION. 

Many degenerative changes may appear from narrowing of 
the blood-vessels, such as softening of the brain, fatty degen- 
eration of the heart, etc. 

Symptoms. — Great changes may take place in the arteries 
without giving rise to symptoms. The condition is easily 
recognizable if the external arteries are the ones affected ; 
thus, the hardening in the radial and temporal arteries may 
be felt, but the internal arteries are not open to scrutiny. 
The principal symptoms depend upon the high-tension pulse, 
which is full and strong and difficult to obliterate. Next in 
importance are changes which relate to hypertrophy of the 
heart, particularly the left ventricle. The apex-beat is dislo- 
cated downward and to the left, the impulse being forcible 
and heaving ; the second aortic sound is clear, ringing, and 
accentuated. The involvement of the coronary arteries may 
develop symptoms of angina pectoris. If there be changes 
in the cerebral vessels, paralysis of various kinds may result. 
The ophthalmoscope may reveal changes in the retinal 
vessels. 

Vertigo is a prominent and frequent symptom. Urinary 
symptoms occur in a majority of the cases. The urine is in- 
creased in amount, of low specific gravity, rarely containing 
casts or albumin, pointing strongly to contracted kidney, 
which often is associated. If dilatation follow hypertrophy of 
the heart, relative insufficiency develops. This may be diffi- 
cult to diagnosticate from actual organic valvular defects. The 
urine under such a condition will have changed, being lessened 
in amount, and of high specific gravity, containing albumin and 
casts (due to congestion of the kidney). Edema may result, 
as in failing compensation from valvular disease. Respiratory 
symptoms occasionally appear, such as relate to bronchitis 
and allied conditions. 

Diagnosis. — This depends upon the tortuous temporal 
arteries, hard, whip-like radials, high-tension pulse, accent- 
uated second aortic sound, and hypertrophy of the left ven- 
tricle. 

When the atheromatous condition involves the internal 
arteries, the diagnosis is more difficult, and the accentuation 
of the second aortic sound and hypertrophy of the left ven- 
tricle are less distinct. 

Prognosis. — The prognosis varies in individual cases. The 
patient may live for some time but the changes in the arteries 
are never amenable to cure. 



ANEURYSM. 365 

Treatment. — The patient's life should be carefully regu- 
lated, excesses avoided in food and drink, and there should 
be no exertion of any description, mental quietude being 
insisted upon. Alcohol should be absolutely prohibited. 

If the history of syphilis occur in the case, a prolonged 
treatment by iodid of potassium is of use. In other cases, 
the best results are obtained by giving the nitrites, such as 
the nitrite of sodium or nitroglycerin. The bowels should 
be carefully regulated. 



ANEURYSM. 

Definition. — "An aneurysm is a circumscribed tumor, 
containing fluid or solid blood, communicating directly with 
a canal of an artery, and limited by a tunic which is called 
the sac" (Hilton Fagge). 

Etiology. — Trauma is an important etiologic factor. Any 
condition which weakens the wall of a blood-vessel may give 
rise to aneurysm ; thus, arteriosclerosis is an important cause. 
Any condition which raises local blood pressure may be 
causative, such as muscular effort, heavy lifting, wrestling, 
sudden fright, straining at stool, parturition, etc. Syphilis is 
important ; many authors estimate as high as eighty per cent, 
of all cases due to this cause. Alcohol, in giving rise to arterio- 
sclerosis, may be mentioned as a causative factor. Gout and 
lead-poisoning act in the same manner. The greatest num- 
ber of cases occur between the ages of thirty and forty, and 
aneurysm is more frequent in the male than in the female. 

General Considerations. — Dilatation may occur in any 
artery in the body, so that an aneurysm may vary in size from 
the so-called miliary aneurysm to an immense tumor. The 
condition is more frequent in some countries than in others ; 
thus, it is comparatively rare in Germany, France, and Italy, 
but more frequent in England. The greater number of 
aneurysms in this country occur in foreigners. The majority 
of aneurysms appear in the thoracic aorta, next in the abdom- 
inal aorta, the subclavian artery, and the innominate artery. 
In the aorta itself, the arch seems to be affected in the greatest 
proportion of cases. 

External aneurysms belong particularly to the domain of 
surgery, internal medicine having to do chiefly with aneurysm 
as it occurs in the aorta and its main divisions in the chest and 
abdomen, and the miliary aneurysm, particularly of the brain. 



366 DISEASES OF THE CIRCULATION. 

In the brain the middle cerebral artery is affected most fre- 
quently. 

Pathology. — Varieties. — Aneurysms may be true or false. 
A true aneurysm is a circumscribed dilatation of one or more 
coats of an artery. A false aneurysm has for its wall the sur- 
rounding tissues, the blood-vessel having ruptured. Aneu- 
rysm may also be classified as regards its shape ; when oval or 
spindle it is called fusiform, or cylindric aneurysm. When one 
portion of an artery is dilated into a pouch-like formation it is 
called a saccular aneurysm ; when the blood finds its way be- 
tween the coats of an artery, as a result of rupture of the 
inner coat (the middle coat may also be ruptured), it is called 
a dissecting aneurysm. 

As has before been stated, the usual cause of aneurysm is 
arteriosclerosis. The blood-vessel loses its elasticity, the ves- 
sel becomes weakened, and any sudden strain may cause it to 
give way. 

Miliary aneurysms are sometimes produced as a result of 
destruction of the outer coats of a vessel ; for example, in a 
tuberculous lung, the process involving the larger blood- 
vessels. The outer coat becomes diseased and the inner pro- 
trudes, forming what is called miliary aneurysm. Again, an 
aneurysm may become very large, in some instances reaching 
an enormous size. The aneurysmal sac may contain lamin- 
ated clots, often being healed. In very old aneurysms this 
clot may assume the appearance of being fibrous. In many 
aneurysms, however, no coagula are to be found. Atrophy, 
from pressure of surrounding tissues, commonly accompanies 
aneurysm. The vertebras, the ribs, and the sternum are not 
infrequently involved, and portions of these structures may 
entirely disappear. Pressure upon the bronchi may cause 
bronchiectasis, and pressure on the lung, atelectasis. 

Rupture may result in the form of a slow leak or rapid 
gush. When the first portion of the arch of the aorta is 
involved the rupture may occur into the pericardium (see 
Hemopericardium). The rupture of the thoracic aorta may 
take place externally, into the pleural sac, mediastinum, bronchi, 
trachea, lungs, and esophagus. Rupture into the superior vena 
cava has been reported. External rupture is not uncommon. 

Aneurysm of the abdominal aorta may cause atrophy of 
the vertebras and surrounding structures. Rupture may take 
place externally or into the peritoneal cavity. Aneurysms of 
the brain may be of quite large size or of the miliary character. 



ANEURYSM. 367 

Hypertrophy of the heart, as a rule, occurs, being chiefly due 
to the arteriosclerosis which usually precedes the development 
of aneurysm. 

Symptoms. — The symptoms may be latent for a long 
period. The early diagnosis of aneurysm is often impossible, 
the symptoms being misleading. Among the earliest and 
most important symptoms is pain. It may occasionally 
be absent, but in the majority of cases it is the first, most 
important and enduring symptom. It differs greatly in con- 
tinuity, variability, and character. It may be slight, or, on 
the other hand, severe enough to threaten life, or disturb the 
comfort and rest of the person affected. It is usually acute 
and paroxysmal, subject to remissions and exacerbations, or 
it may be dull, gnawing, and localized in the position in which 
the aneurysm occurs. Paroxysmal pain in some region in 
close relation to the aorta is always suggestive of aneurysm. 
The pain is often worse at night. In abdominal aneurysm the 
pain is likely to be severe and shoot through to the spine. 
It is intense and wearying in character, and rarely absent. 
The heart may remain entirely free from signs or symptoms 
for some time. However, in a number of cases palpitation 
occurs. 

Important symptoms are pressure phenomena ;• thus, the 
pain may often be due to the aneurysmal sac pressing upon a 
nerve-trunk. Occasionally there is hyperesthesia and anes- 
thesia. Hoarseness and aphonia may result from pressure 
upon the recurrent laryngeal nerve. Unilateral sweating and 
change in the size of the pupils are often symptoms of pres- 
sure upon the sympathetics. From pressure, particularly 
upon the left bronchus, tracheal tugging occurs. Pressure 
upon the pneumogastric may cause vomiting, and upon the 
esophagus may give rise to dysphagia. As a result of pres- 
sure upon the thoracic duct there may be extreme emaciation. 
Pressure upon the bronchus may result in dyspnea, which 
may be paroxysmal in character. 

Cough and hemoptysis are frequent symptoms in aneurysm 
of the aorta. Pressure upon the superior vena cava may 
give rise to distention of the veins of the neck and face, caus- 
ing cyanosis with edema. Pressure upon the inferior vena 
cava gives rise to similar conditions of the limbs and con- 
gestion of the viscera. 

Changes in the pulse may occur, especially if the aneurysm 
is situated in the ascending part of the aorta ; the pulse, com- 



368 DISEASES OF THE CIRCULATION. 

pared with the apex-beat, is retarded. In the ascending 
aorta the carotid pulse may also be delayed. The location 
of the aneurysm may cause a delayed pulse of one side ; for 
example, the left carotid and subclavian pulse may follow 
those of the right side. 

Physical Signs of Thoracic Aneurysm. — Inspection. — 
If the aneurysm have eroded the ribs or sternum, protrud- 
ing itself externally, a pulsating tumor is seen, often pro- 
ducing a blue or livid discoloration of the skin. 

Palpation. — Palpation may show a downward displacement 
in the apex-beat of the heart, due to pressure from above 
downward and to the left, without signs of marked hyper- 
trophy. The aneurysm, if palpable, reveals an expansile 
pulsating tumor, and a more or less distinct thrill, which is 
systolic in time. Tracheal tugging may also be noticed upon 
palpation. A distinct diastolic shock may sometimes be pres- 
ent over the base of the heart. 

Percussion. — Percussion elicits flatness over the tumor. 

Auscultation. — Auscultation gives a distinct systolic bruit 
from the rush of blood through the distended tumor. 

Signs of Rupture. — Rupture of an aneurysm is recognized 
by the instant collapse of the tumor, and symptoms of pro- 
fuse and rapid hemorrhage. 

Diagnosis. — The diagnosis depends upon the recognition of 
the etiologic factor ; the symptoms of pain, palpitation, and 
dyspnea, presence of tumor, with expansile pulsation, thrill, 
and bruit, and often dislocation of the apex-beat of the 
heart, accompanied by pressure phenomena. 

Prognosis. — The prognosis is always grave, although cure 
may take place. 

Treatment. — Absolute rest in bed is of the utmost import- 
ance. A diet in which fluids are largely eliminated (Tufnell 
treatment) is of use in some cases. The symptomatic treatment 
consists in the administration of large doses of iodid of potas- 
sium. The use of opium for the relief of pain should be 
delayed as long as possible. 

Surgical Treatment. — The surgical treatment may consist 
in ligation, filipuncture, needling, electropuncture, compression 
and wiring, wiring with electrolysis,' and the hypodermic use 
of gelatin. 



ANEURYSM. 369 



ANEURYSM OF THE ABDOMINAL AORTA, 

Etiology. — The same causes which give rise to aneurysm 
of the thoracic aorta produce aneurysm of the abdominal 
aorta. The pressure symptoms relate more to the abdominal 
viscera and the lower extremity. The pain is constant, gnaw- 
ing, shooting through to the back, and may radiate down the 
legs. The physical signs are the same as those in thoracic 
aneurysm, although the tumor is not nearly so likely to make 
its appearance. 

Diagnosis. — Occasionally, masses of various kinds, such 
as tumors of the left lobe of the liver, of the stomach, or of the 
pancreas, or large glands, may give rise to some of the physi- 
cal signs of aneurysm. However, the expansile pulsation is 
absent, although this is sometimes difficult to determine. If, 
then, the patient be placed in the knee-elbow position, and if 
the tumor falls forward, the signs of aneurysm will disappear. 

Prognosis.; — The prognosis is practically the same as that 
of thoracic aneurysm. 

Treatment. — The treatment before described for thoracic 
aneurysm should also be adopted in cases of aneurysm of the 
abdominal aorta. 



24 



PART IIL 

DISEASES OF THE RESPIRATORY 
SYSTEM. 



DISEASES OF THE NOSE. 

ACUTE RHINITIS. 

Definition. — An acute catarrhal inflammation of the nasal 
mucous membrane, characterized by copious secretion of a 
serous or mucous character. 

Synonyms.— Acute coryza ; acute nasal catarrh. 

Etiology. — The affection is most often caused by cold and 
exposure, although it may result from trauma and the inhala- 
tion of irritants. 

Pathology. — In the first stage there is hyperemia and 
slight swelling of the mucous membrane and of the tur- 
binated bones, accompanied by dryness of the membrane. 
This is followed by a profuse serous or mucoserous dis- 
charge, which later may become purulent. 

Symptoms. — The attack may begin with slight chilliness 
and malaise, with some headache and pain referred to the 
nasal and frontal bones. The temperature is subfebrile, and 
the pulse is not altered. Stenosis of one or both nasal cham- 
bers may occur, due to the swelling of the mucous membrane 
of the nose. This is followed by profuse discharge of a 
mucous, serous, and finally seropurulent character. Sneezing 
is common, and the conjunctivae may be injected. The dis- 
charge is sometimes acrid, and the lips and anterior parts of 
the nose may be slightly excoriated. 

Complications. — The inflammatory process may invade the 
frontal sinus, the antrum of Highmore, the Eustachian tube, 
and the nasopharynx. 

Prognosis. — Uncomplicated cases recover in from five to 

37o 



CHRONIC RHINITIS. 371 

seven days. It must be remembered that the disease may 
aggravate a preexisting nasal or pharyngeal condition. 

Treatment. — Prophylaxis consists in the avoidance of 
cold ; and persons who are subject to nasal catarrh should 
undergo a hardening process by means of hydrotherapy, etc. 
Mild alkaline nasal washes and a weak solution of cocain 
applied to the nose gives temporary relief. Where there is 
great secretion, small doses of atropia or tincture of belladonna 
are useful. 

CHRONIC RHINITIS. 

Definition. — A chronic catarrh of the nasal mucous mem- 
brane, frequently implicating the nasopharynx and giving rise 
to hypertrophy, especially of the turbinated bones. 

Synonyms. — Chronic nasal catarrh ; postnasal catarrh. 

Description. — There are several more or less well-defined 
varieties of chronic nasal catarrh, (i) Simple clironic catarrh, 
in which there is irritability of the mucous membrane, espe- 
cially of the septum and turbinated bones. There is clogging 
of one or both nostrils, and the patient has a special liability 
to catch cold. The nasal secretion is thick and tenacious. 

(2) Hypertrophic rhinitis is characterized by hypertrophy of 
the turbinated bones, causing a partial or complete stenosis. 
Adenoid vegetations are apt to occur in this form. From the 
stenosis of the nasal passages the affected person becomes a 
" mouth-breather," and this condition is apt to be aggravated 
at night. 

When this disease occurs in young children, and especially 
when complicated by adenoids, the facies become dull and 
stupid, and deformities of the chest are apt to develop. 

(3) Atrophic rhinitis may be the result of the hypertrophic 
variety. On account of the foul odor which comes from the 
nose, the condition has been called ozena and coryza fcetida. 
Ozena is a name given to any foul discharge from the nose, 
and may be a symptom of syphilis, glanders, foreign bodies in 
the nose, necrosis, etc. 

The disease occurs more often in women than in men, 
and especially in the early periods of life. Upon inspection 
the mucous membrane in this variety is thin and covered with 
grayish white crusts, which on removal leave an excoriated 
surface, but very rarely a true ulcer. The symptoms are loss 
of smell, even to the offensive odor which comes from the 
nose. 



372 DISEASES OF THE RESPIRATORY SYSTEM. 

Treatment. — Thorough cleansing of the nasal surfaces is 
important ; reduction of growths, and hypertrophied tissue 
gives relief. The condition had better be treated by a spec- 
ialist. 



DISEASES OF THE LARYNX. 

ACUTE LARYNGITIS. 

Definition. — An acute catarrhal inflammation of the larynx. 

Etiology. — Sudden changes in temperature, accompanied 
by moisture, the inhalation of irritant gases, the excessive 
use of the voice in shouting, speaking, or singing may produce 
the condition. It occurs commonly in some of the acute 
infectious diseases, such as influenza, measles, whooping- 
cough, etc., and in the various diatheses, such as the gouty, 
rheumatic, tuberculous, and syphilitic. 

Pathology. — The mucous membrane usually presents a 
mucous exudate with some injection of the surrounding 
blood-vessels, the entire membrane being somewhat swollen. 
Ulcers and vesicles have been noted in this condition. 

Symptoms. — The chief symptoms are soreness or pain in 
the larynx, with a dry, irritating cough, and some degree of 
hoarseness. Later, small patches of mucus streaked with 
blood may be expectorated. Occasionally aphonia may take 
place. There may be slight fever and general malaise. Dys- 
pnea may occur in children. 

Diagnosis. — The laryngoscope reveals an acute inflam- 
mation of the larynx. 

Prognosis. — The prognosis is favorable. 

Treatment. — In severe cases the patient should be kept in 
bed and the atmosphere of the room moistened. The patient 
should refrain from talking. An ice bandage around the neck 
gives great comfort. Inhalations of steam, medicated by com- 
pound tincture of benzoin and paregoric, will allay cough and 
irritation. In children, if dyspnea becomes marked, emetics 
should be used. 

CHRONIC LARYNGITIS 

Definition. — Chronic catarrhal inflammation of the larynx. 

Etiology. — All causes which produce acute laryngitis may 

give rise to the chronic form. This condition frequently fol- 



EDEMA OF THE LARYNX. 373 

lows acute or subacute attacks. Interference with nasal res- 
piration has been given as a potent cause. 

Pathology. — The mucous membrane usually shows some 
thickening, and may be granular. Later in the course of the 
disease atrophic changes and the formation of new fibrous 
tissue may result. 

Symptoms. — The symptoms are hoarseness, and sometimes 
complete loss of voice. Cough is not a constant symptom, but 
if present it may be either dry or productive. If there be 
abundant expectoration, the trachea and bronchi will be 
found to be involved. Constitutional symptoms are, practically, 
always absent. The laryngoscope may show the appearance 
of the vocal cords to be dull, and grayish or pinkish in color, 
both cords being most often affected. 

Diagnosis. — The diagnosis depends upon the etiology, and 
the exclusion of tuberculosis and malignant diseases. 

Treatment. — The treatment should consist in complete rest 
of the voice. The general health should be carefully looked 
after. Local applications to the larynx, and inhalations, are of 
some use. Strychnin to improve the muscular tone is of value. 
Electricity has also been used. 

EDEMA OF THE LARYNX. 

Definition. — This condition is not an independent affection, 
but occurs as a complication in various diseases. The disease 
is commonly called edema of the glottis. The glottis, how- 
ever, being a space, can not become edematous, and the term 
is a misnomer. Two varieties are described, primary and 
secondary, or passive edema. 

Etiology. — Simple edema may arise from trauma, such as 
the swallowing of a hard body and applications of medicines 
to the larynx. A condition may occur in the larynx, similar 
to that which takes place in the skin, known as angioneurotic 
edema. This usually appears during young adult life, and 
most frequently in women. Edema of the larynx may arise 
from the administration of some drugs — for example, iodid 
of potassium. Primary edema may also arise from infectious 
conditions, such as the entrance of micro-organisms into the 
larynx. It occurs in some of the infectious diseases, such as 
enteric fever, diphtheria, hydrophobia, etc. 

Secondary edema may be due to tuberculosis, syphilis, 
carcinoma, and may occur from some of the infectious diseases, 



374 DISEASES OF THE RESPIRATORY SYSTEM. 

such as influenza, smallpox, etc. It may be due to the inflam- 
mation of a deep cervical gland. The general causes are those 
which give rise to dropsy, such as disease of the heart, 
kidneys, lungs, etc., or from pressure from new growths of the 
mediastinum, etc. 

Symptoms. — The patient complains of pain in swallowing, 
and a feeling as if there were a foreign body in the throat. The 
voice is thick and muffled, or there may be aphonia. As 
the glottis does not close completely, the patient is likely 
to choke on taking food into the mouth and swallowing, as 
particles of the ingested substances may get into the larynx. 
Respiration becomes difficult and orthopnea may take place. 
If death is threatened, the patient presents the symptoms of 
suffocation. The laryngoscope shows the mucous membrane 
to be tense, pale, and swollen. 

Prognosis. — General edema is a serious condition. The 
prognosis depends upon the cause. If the condition be due to 
sepsis it is almost invariably fatal. 

Treatment. — The treatment is that of dropsy occurring in 
other parts of the body. Surgical treatment, such as scarifi- 
cation, intubation, tracheotomy, etc., is often necessary. 

LARYNGISMUS STRIDULUS. 

Synonym. — Spasm of the larynx. 

A disease limited to neurotic individuals, occurring in both 
children and adults. 

SPASM OF THE LARYNX IN CHILDREN. 

Rickety children are subject to this affection, in whom it 
often appears as a reflex disturbance from teething, indigestion, 
intestinal parasites, exposure to cold, catarrh of the air-pas- 
sages, irritation of the prepuce, and cerebral or cerebrospinal 
disease. It is most common in infants under the age of two. 

Symptoms. — The disease comes on abruptly, the child being 
attacked most often at night with shortness of breath, followed 
by closure of the glottis, which remains closed sometimes for 
twenty or thirty seconds. The face during this period be- 
comes anxious, and cyanosis is a prominent feature. This is 
followed by relaxation of the spasm, giving rise to a high- 
pitched inspiration. The spasm may repeat itself several times 
and then subside, returning after a day or two. These recur- 
rences may continue for a period of several weeks, with 



croup. 375 

gradual improvement. The disease may, however, prove 
fatal, the child choking to death. Convulsions occur if the 
attack be very severe. 

Prognosis. — The disease may prove fatal, particularly in 
boys. 

Treatment. — Any constriction about the neck must be 
speedily loosened, and as much fresh air admitted to the room 
as possible. The feet may be immersed in a hot mustard 
bath, cold compresses being applied to the head and chest ; 
and sinapisms to the nape of the neck are useful. Hypo- 
dermics of morphin and atropin may be given in severe cases. 
Chloral, by the bowel, is occasionally very useful. Compres- 
sion of the phrenic nerve with the index finger placed between 
the two lower attachments of the sternocleidomastoid muscle, 
frequently repeated, has been successful. Intubation and 
tracheotomy is necessary when the attack is severe and con- 
vulsions are threatened. Emetics are also useful in this condi- 
tion. Tonic treatment, such as cod-liver oil, syrup of the iodid 
of iron, etc., should be given. Good hygiene is of importance. 

SPASM OF THE LARYNX IN ADULTS. 

The condition is usually reflex, due to some underlying 
disease. It is never fatal. It may be due to the entrance of 
a foreign body into the larynx, or to a laryngeal tumor, and 
the ulceration from syphilis or tuberculosis may give rise to it. 

Symptoms.— The attack comes on at night with similar 
symptoms to those occurring in children, but the recurrences 
are not so frequent nor so severe. 

Prognosis. — The prognosis is favorable. 

Treatment. — Antispasmodics are of use. The spray of a 
4^ solution of cocain, or antipyrin administered by the mouth 
usually promptly overcomes the spasm. Severe measures are 
rarely ever necessary. 

CROUP. 

Synonyms. — Spasmodic croup ; pseudodiphtheria. 

Etiology. — This affection is probably due to some infec- 
tious agent which has not yet been discovered. It frequently 
follows sudden chilling of the body, the attacks occurring par- 
ticularly in children before the age of puberty. Heredity 
plays some part as an etiologic factor. The condition consists 
of a catarrhal inflammation with slight exudate. 



376 DISEASES OF THE RESPIRATORY SYSTEM. 

Symptoms. — The attack begins suddenly, most often at 
night. The first indication is usually a hoarse, metallic cough, 
followed by dyspnea. The dyspnea may become extreme, 
and the child gasp for breath. Cyanosis of the face and ex- 
tremities occurs in extreme cases. The temperature may be 
elevated from 102 F. to 104 F. The cough is usually unpro- 
ductive, but toward the close of the attack free expectoration 
may take place. Albuminuria may occur as in other infec- 
tious diseases. 

Diagnosis. — The disease may be mistaken for diphtheria, 
but a bacteriologic examination will show the presence of 
the Klebs-Loffler bacillus in diphtheria. 

Prognosis. — Favorable. 

Treatment. — The child should be at once immersed in a 
warm bath, and an emetic promptly given. Syrup of ipecac 
or turbeth mineral may be used for this purpose. Between 
the attacks the child should have tonic treatment of cod-liver 
oil, syrup of the iodid of iron, or compound syrup of the 
hypophosphites. 



DISEASES OF THE BRONCHI. 

BRONCHITIS. 

This disease is divided into two varieties, acute and chronic 
bronchitis. 

SIMPLE ACUTE BRONCHITIS. 

Synonyms. — Acute catarrhal bronchitis ; acute bronchial 
catarrh and acute trachitis. 

Definition. — Acute bronchitis is an inflammation of any 
part of the bronchial mucous membrane, excepting the term- 
inal bronchial tubes. 

Etiology. — This disease occurs at any age. Sudden 
changes in the weather, especially damp and cold weather, 
give rise to this affection. Very hot rooms and bad ventila- 
tion and wetting of the feet are causative factors. Inhalation 
of noxious gases and chemicals may produce the disease. It 
occurs in many of the acute infectious diseases, such as 
enteric fever, influenza, and whooping-cough ; also in many 
chronic affections of the heart, particularly in valvular disease 
characterized by failing compensation. It is also found in 
chronic renal disease, diabetes, gout, and in chronic diseases 



BRONCHITIS. 377 

of the spinal cord. Occupations which give rise to exposure 
and the vicissitudes of the weather, such as the coachman, 
laborer, etc., are important predisposing factors. The admin- 
istration of some drugs, particularly iodid of potassium, may 
cause acute bronchitis. 

Pathology. — By many the affection is believed to be of 
microbic origin. The mucous membrane of the trachea and 
larger bronchial tubes, and sometimes the smaller tubes, are 
affected. When the irritant lodges upon the mucous mem- 
brane the first change produced is a granular degeneration of 
the epithelial cells and congestion of the part, followed by 
desquamation of the epithelium, later infiltration of the sub- 
mucosa with leukocytes and swelling of the mucous glands. 
The mucous surface is dry, and it appears injected. Later a 
muco or mucopurulent exudate may be found upon the sur- 
face. Some of the bronchial tubes may be more or less com- 
pletely filled with this exudate, which often collects at the 
bifurcation of many of the bronchi as a result of the stream 
of expired air. In this manner small masses of exudate are 
expectorated. 

Microscopic examination of the expectoration reveals the 
following : it usually contains many epithelial cells, various 
micro-organisms, leukocytes, and sometimes red blood-cells, 
depending upon the severity of the lesion. The disease may 
be localized to almost any area, such as the trachea, — being 
called trachitis, — or one or more bronchial tubes, and if the 
condition extends into the smaller bronchial tubes and alveoli, 
bronchopneumonia results. 

Symptoms. — Acute bronchitis usually begins with pain of 
moderate intensity in the chest, the pain being referred to the 
region under the sternum. There may also be muscular pain, 
especially of the intercostal muscles. Cough is an early 
symptom ; it may be due to the accompanying laryngitis, but 
more frequently to irritation of the mucous membrane of the 
trachea and larger bronchi. The intensity of the cough 
varies in different cases. It is at first unproductive, or a very 
small patch of glairy mucus may be brought up, later becom- 
ing mucoid or mucopurulent. Occasionally the expectoration 
may be tinged with blood. This occurs particularly in ca- 
chetic individuals and in those of an alcoholic temperament. 
Dyspnea is moderate. There may be slight fever, the tem- 
perature ranging from ioo° to 102 F. The appetite is lost, the 
patient generally being uncomfortable. In infants, catarrh of 



37 8 DISEASES OF THE RESPIRATORY SYSTEM. 

the nose and throat usually precedes the attack of bronchitis, the 
respirations being increased in frequency, the nursing child 
rejecting the nipple and pausing before resuming to nurse. 
This is due to the fact that the mucous membrane of the nose 
is affected, the child being unable to respire while the nipple 
is in its mouth. The temperature in the bronchitis of infancy 
rarely exceeds 102 F. or 103 F. Should the temperature rise 
above this, the physician should be upon the alert, as it is most 
likely that the finer tubes have become implicated and a bron- 
chopneumonia has developed. In ordinary cases the attack 
lasts about a week, the expectorations becoming looser after 
the fourth or fifth day. In subacute forms of the disease the 
symptoms may be less marked, and the duration of the affec- 
tion longer. 

Physical Signs. — If the process affect the upper part of 
the trachea alone, the laryngoscope may reveal a pinkish or 
red appearance of the mucous membrane, and physical signs 
may be entirely absent. 

Inspection. — The inspection is negative. 

Palpation. — The palpation is negative, giving the signs of 
normal lung structure. 

Percussion. — Normal pulmonary resonance is produced 
upon percussion, the exudate in the bronchial tubes not being 
sufficient to obscure the note. 

Auscultation. — Upon auscultation, dry rales are at first 
heard, followed later by large and small moist rales. These 
are heard both anteriorly and posteriorly over the entire chest. 

If the inflammatory process affects the trachea and the 
largest bronchi, no rales may be present at all, as the exudate 
in the first stage is not great enough to materially lessen the 
lumen of the tubes. 

Diagnosis. — The diagnosis depends upon the history of 
exposure, the substernal pain, the dry cough, followed by an 
expectoration of a muco or mucopurulent character, with the 
occurrence of dry and moist rales. 

Treatment. — The prophylaxis consists in the avoidance of 
injurious influences and a hardening process should be insti- 
tuted by means of hydrotherapy in the young, especially those 
who are predisposed. The temperature of the room should 
be between 68° F. and yo° F. In the first stage steam inhala- 
tions are of use. Mustard plasters and turpentine stupes, 
applied to the chest, are often beneficial. For the cough, 
opium or its derivatives are best. Expectorants should be 



BRONCHITIS. 379 

given when the cough becomes looser. In adults, heroin in 
^ of a grain doses acts well. 

FIBRINOUS BRONCHITIS, 

Synonyms. — Plastic bronchitis ; croupous bronchitis. 

Etiology. — This is a rare disease, occurring after inhalation 
of noxious gases such as ammonia, and steam. It may be 
acute, but is usually chronic. It has been observed during 
the course of erysipelas, scarlet fever, enteric fever, and other 
diseases. 

The exudate which appears occasionally in the bronchial 
tubes during an attack of diphtheria should be regarded as 
diphtheria, and not as ordinary fibrinous bronchitis. 

Pathology. — The larger or smaller tubes may be affected, 
the fibrinous exudate being formed upon the surface of the 
mucous membrane of the bronchi. The exudate varies in 
firmness. The expectorated material will be found to con- 
tain casts of the bronchial tubes. These are easily recog- 
nized by allowing the sputum to be placed in water and 
teased apart. 

The exudate is found to consist chiefly of fibrin. Some of 
the epithelial lining may adhere to this ; leukocytes and occa- 
sionally red blood-cells are also found, as well as Charcot- 
Leyden crystals, and eosinophilic cells. 

Symptoms (of the Acute Form). — The acute form is 
very rare, and cases may occur in children. Prodromes may 
take place, such as slight headache, cough, and malaise. A 
chill, however, may usher in the attack. It is followed by 
dyspnea, cough, scanty expectoration, and severe substernal 
pain. The dyspnea increases in severity and may give rise to 
symptoms of suffocation. The cough becomes severe and 
paroxysmal, and may have the hoarse tone of laryngeal croup. 
The sputum, at first, is not characteristic, and may contain 
slight amounts of blood. Rarely, fibrinous fragments are 
brought up in the early stages of the disease. Later, entire 
casts of the bronchi may come away with a violent expulsive 
effort, with free hemoptysis, relief of all the symptoms 
following at once. With ensuing recovery the symptoms 
abate. If this favorable event does not occur, the disease 
may prove fatal in from a few days to a few weeks. 

Symptoms (of the Chronic Form). — In the chronic 
form the symptoms may come on after a more or less prolonged 
attack of bronchitis, although the disease may begin abruptly 



380 DISEASES OF THE RESPIRATORY SYSTEM. 

as in the acute form. The symptoms are the same as those 
recorded in the acute form, and they may assume all grades 
of severity. 

Recovery is, however, the rule, although the general health 
of the patient may be greatly impaired by the frequency and 
severity of the successive attacks. The signs of emphysema and 
atelectasis or consolidation may occur in the chronic variety, 
although in the uncomplicated disease the percussion note is 
not changed. No rales are characteristic of this condition, but 
sonorous and sibilant rales commonly occur. Diminished 
thoracic expansion may be observed on the affected side. 

Complications and Sequels. — Tuberculosis, pneumonia, 
and very frequently compensatory emphysema may develop. 
If the affected bronchus becomes impervious, atelectasis re- 
sults. 

Diagnosis. — The disease is extremely rare, and can only 
be diagnosticated by the characteristic sputum. It may be 
mistaken for laryngeal diphtheria, and a bacteriologic exami- 
nation of the exudate may be necessary. 

Prognosis. — When this disease occurs in the acute form in 
previously healthy individuals, recovery may take place. The 
chronic form in cachectic individuals is fatal. A high range 
of temperature is unfavorable, especially if pulmonary com- 
plications occur. Hemoptysis is not necessarily a serious 
complication. 

Treatment. — No agents are known which are of avail in 
loosening or softening the fibrinous exudate. Inhalations of 
steam are often useful. In robust individuals emetics may be 
beneficial. Opiates are necessary when there is severe pain. 

CHRONIC BRONCHITIS. 

Definition. — Chronic catarrh of the bronchial tubes. 

Varieties. — Chronic dry catarrh ; bronchorrhea ; fetid bron- 
chitis. 

Etiology. — This is a disease of middle life or advancing 
years, and is rare in young subjects. It often follows repeated 
attacks of acute bronchitis, and all the etiologic factors con- 
cerned in the acute form are causative in the chronic variety. 
The disease may assume a chronic type from the beginning ; 
this occurs especially in older persons, or in those who suffer 
from constitutional cachexia, gout, renal disease, cardiac dis- 
ease, or alcoholism. The disease is often symptomatic, accom- 
panying chronic pulmonary tuberculosis, emphysema, and 



BRONCHITIS. 381 

asthma. In chronic valvular lesions, especially mitral disease, 
in which pulmonary congestion occurs, chronic bronchitis is 
likely to be present. 

Pathology. — The bronchi, bilaterally, are usually affected, 
and only in rare instances are local lesions found. Such a 
condition may be the result of tuberculosis. 

The bronchi may show a variety of lesions ; the mucous 
membrane may be greatly thickened, marked proliferation 
of the epithelial cells and desquamation being found. Profuse 
muco or mucopurulent exudation may be present, or the 
bronchi may show atrophic changes. The mucous membrane 
is thinned, the character of the epithelium changed, and in 
some instances the epithelium is absent. Sclerotic changes 
may be present, and contraction results in narrowing of the 
lumen, or bronchiectatic changes may follow. Emphysema 
commonly follows chronic bronchitis. The expectoration may 
vary, in some instances being profuse and watery, or it may 
be mucopurulent and, rarely, completely absent. The expec- 
torated material contains epithelium, often being modified ; 
also leukocytes, rarely red blood-cells, Charcot-Leyden crys- 
tals, and various micro-organisms. 

Symptoms. — Cough, expectoration, and disturbance of 
respiration are the principal symptoms. The cough is variable, 
and is usually severer early in the morning, when the exudate 
which has accumulated during the night begins to shift its 
position, and the patient is compelled to cough until the 
exudation is dislodged and brought up. The cough may be 
hacking, dry, or paroxysmal. In the dry variety it is not 
productive. The sputum may consist of tough masses, 
resembling coins, of circular form, termed "nummular" 
expectoration. In many instances it is abundant and purulent, 
or it may be abundant and thin. The dyspnea occasionally 
may be quite marked ; in other instances it is insignificant. 
When the bronchitis occurs in cardiac or renal disease the 
dyspnea is often marked, and is then due to the underlying 
condition. 

Physical Signs. — Inspection. — The inspection is negative, 
except that dyspnea may be apparent. 

Palpation. — Palpation is negative, unless large quantities of 
fluid be contained in the tubes, when the vocal fremitus may 
be diminished. If there is but a small quantity of fluid in the 
large tubes, bronchial fremitus may be felt, known as the 
'* rhonchus." 



382 DISEASES OF THE RESPIRATORY SYSTEM. 

Percussion. — In uncomplicated cases percussion gives 
normal pulmonary resonance. If emphysema occurs the signs 
relating to this condition are present. 

Auscultation. — Upon auscultation, all varieties of rales are 
heard diffused through the chest. Occasionally they may be 
moist, and sometimes dry. They are usually heard at the 
lower parts of the lungs posteriorly, due to the extravasation 
of the fluid to the dependent portions. In these areas the 
respiratory murmurs may be obscured and be bronchovesicular 
in character. 

Dry Bronchitis (sometimes called Dry Chronic Catarrh). — 
In this form the expectoration is slight, tough, and tenacious, 
or may be absent altogether. Upon auscultation, dry rales 
occur. Emphysema is a complication, and attacks of asthma 
are common. 

Bronchorrhea. — A rare form, characterized by an excessive 
amount of secretion. The character of the expectoration dif- 
fers : in some instances it is thin and watery, or it may be trans- 
parent and ropy ; this variety was termed by Laennec " chronic 
pituitous catarrh." Under some circumstances the expectora- 
tion is of a mucous, semifluid consistence. This variety has 
been termed "purulent bronchorrhea." The quantity of ex- 
pectoration varies from one to three pints. The fluid com- 
monly separates into three layers, the upper one composed 
of a frothy material, the middle one consisting of a clear, thin 
fluid, and the lower one a viscid, purulent or cellular substance. 

The pathology of bronchorrhea is not well understood ; 
however, emphysema is constantly present, due to the bron- 
chial channels being filled with a secretion. Bronchiectasis is 
also likely to be associated. 

Dyspnea and cough are always present, often being persist- 
ent and paroxysmal. In the early morning, a spell of cough- 
ing and expectoration, which may last for several hours, is 
frequently followed by comparative freedom for the remaining 
portion of the day. Asthma often complicates the disease. 
Anemia and night-sweats have been noted as accompanying 
symptoms. 

Fetid Bronchitis. — In this variety of bronchitis the secre- 
tions undergo decomposition and give rise to foul odors. 
Bronchiectasis is very apt to be present. The disease is usu- 
ally chronic. It may arise in the course of other diseases. 
There is great impairment of the general health ; fever may 
develop, and there may be much pain and coughing. It is 



BRONCHIECTASIS. 383 

easily diagnosticated on account of the foul odor, not only of 
the expectoration, but of the breath. Bronchopneumonia 
may develop, and the condition may terminate in gangrene of 
the lungs. Clubbed fingers and arthropathies may occur. 

Prognosis. — The prognosis is guarded. 

Treatment. — The treatment consists in meeting the indica- 
tions as they arise. Disinfectants may be of use ; carbolic 
acid in form of a weak spray and turpentine internally may 
have some influence upon the fetor. The apartments of the 
patient must be thoroughly ventilated, and a formalin lamp 
may be necessary for thorough disinfection. 

Course of the Disease. — The course of chronic bronchitis 
is protracted, remissions and exacerbations occurring, greatly 
influenced by the season, so that in summer the cough may 
be at times entirely absent. When the disease has existed for 
many years, pulmonary emphysema or tubercular infection 
may result. The right heart dilates, with or without hyper- 
trophy. 

Diagnosis. — The diagnosis is not difficult. It is important 
to determine whether the bronchitis is a primary disease or a 
secondary manifestation of other diseases, such as those of the 
heart, kidneys, gout, or cachexias, etc. 

Prognosis. — The disease is not amenable to cure. There 
may be frequent improvements and relapses. Commonly, 
changes develop, which have just been described, such as 
emphysema, bronchiectasis, and hypertrophy of the heart. 

Treatment. — The patient should be removed to as favor- 
able an atmosphere as possible. Nutritious food in moderate 
amounts is necessary ; it should consist chiefly of fruits, milk, 
and the cereals. Meat should not be allowed in large 
amounts. Alcohol is not necessary in the treatment. In- 
halations of various substances are of little avail. It may be 
necessary to reduce the amount of expectoration or control 
the cough. This is best accomplished by some form of opium. 
The prominent symptoms will require treatment. 

BRONCHIECTASIS. 

Definition. — By bronchiectasis is meant a dilatation of a 
bronchial tube, commonly due to disease of the lungs or bronchi. 

Etiology. — This condition may follow measles or pul- 
monary tuberculosis. In the majority of cases it results from 
a chronic inflammation of the bronchial walls. 



384 DISEASES OF THE RESPIRATORY SYSTEM. 

Foreign bodies in the air-passages, and obstruction from pres- 
sure by aneurysm, tumors, enlarged glands, and cicatricial con- 
tractions in interstitial pneumonia, are factors in the causation. 

It sometimes results from an unresolved croupous pneu- 
monia. 

Pathology. — The condition may be local or general ; the 
dilatation saccular, cylindric, or irregular. Bronchiectasis, in 
the broadest sense of the word, results from obstruction, as 
noted in the etiology. 

The dilated bronchial tubes reveal marked changes in the 
walls of the bronchi. The epithelium may change from the 
cylindric to the squamous variety; the muscular fibers and elas- 
tic tissue show atrophic changes. The cavities are frequently 
filled with an exudate. 

Symptoms. — The cylindric form can not be diagnosticated. 
In the sacculated variety, when there are large cavities, the 
symptoms may be suggestive. There is cough, expectora- 
tion, which may be of large amounts of a mucopurulent char- 
acter, sometimes fetid ; it may suggest gangrene of the lungs 
or a foul-smelling empyema which is connected with a bron- 
chus. The dyspnea depends upon the amount of bronchial 
obstruction ; hemoptysis is uncommon, and may be slight or 
severe. Diarrhea and emaciation may accompany the condi- 
tion. Emphysema, chronic bronchitis and asthma are often 
associated with bronchiectasis. 

Sputum. — In milder cases there is nothing distinctive about 
the sputum. Where there are large saccular cavities, the 
sputum is, however, characteristic. It is abundant, and raised 
in large amounts after a period of retention. It is thin, puru- 
lent, grayish-green in color, and, where decomposition has 
taken place, there is a foul odor. Upon standing, it separates 
into three layers : an upper frothy, a middle thin, and a lower 
thick and granular layer. 

Microscopically, it may be composed almost entirely of pus- 
cells, with more or less fatty epithelial cells, which vary in out- 
line, many being squamous, others cylindric, and forms varying 
between these. Many micro-organisms are usually present. 

Physical Signs. — Over a large bronchiectatic cavity the 
physical signs will vary, depending upon whether the cavity is 
filled or empty, superficial or deep-seated. 

The percussion note will be dull when the cavity is full, or 
high-pitched and tympanitic when the cavity has become 
evacuated after a paroxysm of cough. Deep-seated dilatations 



BRONCHIECTASIS. 385 

are very difficult to detect by percussion, as the sounds elicited 
are modified by emphysema, or by induration of intervening 
lung substance. 

The respiratory changes may consist in feeble expansion 
and diminished murmur, or there may be prolonged ex- 
piration with harsh bronchovesicular breathing. Large 
bronchiectatic cavities, distended with air, may give cav- 
ernous or amphoric breath-sounds. There may be either 
lack of vocal resonance and fremitus, or the vibrations may 
be increased. When there are large cavities posteriorly which 
are partly filled with fluid, bubbling rales may occur. Dry 
and moist rales may also be present, due to associated bron- 
chitis. The physical signs of the associated bronchitis and 
emphysema may be present and lend additional difficulty to 
the diagnosis. 

Complications and Sequels. — Hemorrhage may take 
place, due to ulceration of the bronchial wall. Abscesses and 
induration of the surrounding lung sometimes occur. Pul- 
monary emphysema, with dilatation of the right heart and the 
consequent visceral changes, due to venous congestion of the 
liver, spleen, and kidneys, occur. In prolonged cases, amyl- 
oid degeneration may take place. Arthropathies of the long 
bones, and especially of the terminal phalanges, appear in this 
disease. 

Diagnosis. — The diagnosis in some cases is very easy, and 
when cavities appear they must be differentiated from tuber- 
cular cavities, pulmonary gangrene, and empyema. 

Differential Diagnosis. — 

Bronchiectatic Cavity. Tubercular Cavity. 

Most often situated at the base of the Most often at the apex of the lung. 

lung, the signs being most prominent 

posteriorly. 
Sputum characteristic, foul, and abun- Sputum blood-streaked, not foul, and 

dant. No tubercle bacilli. contains tubercle bacilli. 

No fever nor sweating, and not great Fever, sweating, and great emaciation. 

emaciation. 

Prognosis. — The condition is practically incurable and may 
last for years. 

Treatment. — The general health of the patient must be 
maintained, and inhalations of creasote, turpentine, and euca- 
lyptus, as deodorizing agents, may be useful. Iodid of potas- 
sium in large doses has been advised. Surgical interference is 
justifiable when the physical signs point to an accessible 
cavity. 

25 



386 DISEASES OF THE RESPIRATORY SYSTEM. 

BRONCHIAL ASTHMA. 

Definition. — A condition characterized by paroxysms of 
dyspnea, appearing at irregular intervals, with constitutional 
symptoms. 

Synonyms. — Spasmodic asthma ; nervous asthma ; essen- 
tial asthma. 

Etiology. — Heredity is important, the disease occurring in 
nervous or neurotic individuals, in whom worry or fright is 
apt to bring on an attack. It is common in phthisic families, 
and is likely to appear in persons subject to neuralgic attacks. 

It is a disease of the young, although it is infrequent in in- 
fancy, appearing more often in males than in females. 

The disease may follow attacks of bronchitis, especially of 
that form taking place in the acute infectious diseases, as 
measles, whooping-cough, etc. It is commonly associated 
with chronic bronchitis and emphysema. The inhalation of 
dust, the pollen of certain plants, fog, fumes, vapors, certain 
odors that emanate from some animals may produce an attack 
of asthma. 

Reflex causes, as irritation from nasal polypi or other affec- 
tions of the nasal mucous membrane, and causes relating to 
the gastro-intestinal tract, skin, or genito-urinary center, may 
act in a like manner. It is more common in the Hebrew 
race. 

Pathology. — Three principal theories have been entertained 
as to the origin of this nervous disease : (1) That it is a re- 
sult of bronchial spasm, and the clinical phenomena and the 
effects of certain drugs administered appear to support this 
view; (2) that the symptoms are due to spasm of the dia- 
phragm, but prolonged spasm of the diaphragm would seem 
to be incompatible with respiration ; (3) known as the hyper- 
emic theory, depends upon the irregular, acute swelling of the 
bronchial mucous membrane, a similar condition to that ap- 
pearing upon the skin in urticaria. 

There is no general accepted theory with regard to the 
pathology of asthma. It occurs in families of nervous ten- 
dencies, and the pathology is not uniform in every case. The 
form of asthma in cardiac disease is known as cardiac asthma, 
and the variety in disease of the kidneys, known as renal 
asthma, must not be confounded with this condition. In 
heart and kidney disease asthma should always be considered 
a symptom, and not as a substantive affection. 



BRONCHIAL ASTHMA. 387 

Symptoms. — Usually the attack begins suddenly, but may 
be preceded by prodromes, such as a feeling of general uneasi- 
ness and discomfort, or abnormal sensations in the larynx, 
accompanied by coughing, sneezing, coryza, and tenderness in 
the epigastrium. The attack most often commences at night ; 
the patient awakens with chest pains, great anxiety, and marked 
dyspnea, which causes him to go to the window for fresh air. 
The skin becomes pale and cyanotic. The patient is often 
bathed in cold perspiration. The pulse is increased in fre- 
quency. The temperature may be normal or subnormal, except 
in protracted cases, when from the irritation of the cough 
there may be slight elevation of temperature. 

The respiratory disturbance in asthma is characteristic. 
The inspiration and expiration are accompanied by high- 
pitched whistling rales, which may be heard a considerable dis- 
tance. The accessory muscles of respiration are called into 
play, the expiration being labored and difficult. The sterno- 
cleidomastoid and scaleni may be seen contracting upon 
inspiration. 

Dyspnea is rather expiratory than inspiratory, the difficulty 
being that the patient can not get the air from his lungs. 
Upon percussion there is a tympanitic resonance over the 
lungs. Compensatory emphysema is almost certain to de- 
velop, and the physical signs of this condition may be made 
out. Upon auscultation the vesicular murmur is obscured by 
whistling sounds, these being the dry rales, which at the end 
of a paroxysm give place to moist rales, when expectoration 
also appears. In the majority of cases there is during the 
attack a scanty, tough mucus, followed by a more abundant 
liquid expectoration toward the end of the attack. Small gel- 
atinous masses are often found in the sputum, known as the 
perles of Laennec. 

Upon microscopic examination, the sputum contains leuko- 
cytes, many being eosinophiles, epithelial cells, sometimes 
oxalate of lime crystals, Charcot-Leyden crystals, and Cursch- 
man's spirals. These spirals are supposed to have some rela- 
tion to the pathology of the affection. 

The frequency of the attack is very variable. It may occur 
nightly for some time, and periods of freedom follow lasting 
for months or years. Complete recovery is, as a rule, rare 
after well-developed attacks. In children recovery may be 
looked for oftener than in adults. 

Diagnosis. — The diagnosis is easy, but the symptoms 



388 DISEASES OF THE RESPIRATORY SYSTEM. 

should be carefully studied, in order, if possible, to determine 
the underlying causes. 

Prognosis. — Usually favorable as regards the attack, but 
complete recovery is rare. Emphysema and chronic bron- 
chitis are very apt to develop. 

Treatment. — Persons who are subject to asthma ought to 
live as much as possible in the open air. The living- and 
sleeping-rooms must be well ventilated. A nutritious and 
easily digested diet should be given, and heavy meals at night 
forbidden. Warm and proper clothing in winter and in damp 
weather is essential. 

Treatment of the Paroxysms. — Narcotics and antispasmo- 
dics are usually employed. Chloral, whiffs of chloroform or 
ether, amyl nitrite by inhalation, or morphia and atropia hy- 
podermically are useful drugs. Relief sometimes follows the 
inhalation of nitre paper cigarettes, which also contain lobelia 
and stramonium. Sinapisms and turpentine stupes to the 
chest may be of value. 

Where the attack has lasted some time emetics may be of 
some benefit. 

Treatment between Paroxysms. — Good hygienic sur- 
roundings are necessary. Medicaments which favor nutrition 
in general, cod-liver oil, iodid of iron, courses of arsenic, the 
nitrites, and quinin are of especial use. 

Change of climate and hydrotherapy are useful in most 
instances. 

HAY-FEVER. 

Definition. — Hay-fever is a neurosis characterized by 
symptoms which chiefly relate to the upper air-passages, often 
terminating in asthmatic attacks. 

Synonyms. — Hay asthma ; rose fever ; Bostock's catarrh. 

Etiology. — Summer season and a neurotic temperament are 
predisposing factors, and it is said the exciting factor is pollen 
of flowers. In some cases there is a predisposition to the affec- 
tion from the fact of preexisting chronic nasal trouble. It often 
occurs in gouty and lithemic individuals. There is no doubt 
that in some cases the disease is hereditary. 

Pathology. — No changes have been found that are charac- 
teristic of hay-fever. In many cases there is vascular swelling 
of the nostrils, which may be occluded, and there will gener- 
ally be found a profuse serous exudation. The principal 



HAY-FEVER. 389 

changes which occur are supposed to be due to vasomotor 
paralysis. 

Symptoms. — The symptoms come on about the same time 
each year, sometimes at exactly the same hour and day as on 
the preceding year. 

The early symptoms are usually a sensation of uneasiness, 
such as itching and tickling in the nose and throat, followed 
by more or less frontal headache, lacrimation, sneezing, cough- 
ing, and nasal obstruction. The catarrhal inflammation of 
the eyes, nose, and throat soon becomes intense, and a profuse 
watery discharge from the nostrils appears. The conjunctiva 
is red and painful, and the patient is extremely uncomfortable. 

The degree of severity of these symptoms varies in different 
cases. In some instances they are extremely mild, while in 
others they are quite severe. Occasionally high fever, head- 
ache, and prostration may confine the patient to his bed. At 
the height of the disease the nasal mucous membrane is swol- 
len, which may often show at the anterior nares. 

Sneezing, with a copious flow of mucus from the nose, 
which may even continue so as to disturb the patient's rest at 
night, is common. Cough, although not a constant feature, 
is usual, and may result from an intense bronchitis and last 
some time after the active paroxysm has subsided. Often 
attacks of asthma appear. This comes on late, as a rule, and 
gives rise to symptoms of an asthmatic seizure. Skin erup- 
tions, such as urticaria and herpes, are quite common, and are 
extremely annoying to the sufferer. 

Diagnosis. — The diagnosis is not difficult. The periodicity 
in relation to season, the acute onset, with the catarrhal symp- 
toms, are so definite that the disease can hardly be mistaken 
for anything else. 

Prognosis. — The prognosis as regards life is favorable, but 
very little can be done to abort or prevent a return of the 
attacks. 

Treatment. — A change of climate may alone give perma- 
nent relief. For the eyes mild washes of boric acid are useful, 
and the severe nasal symptoms are temporarily relieved by a 
4.fo or $f solution of cocain. In the gouty cases the treat- 
ment by mineral acids is sometimes of decided benefit. 

Syrup of hydriodic acid is sometimes useful. 



39° DISEASES OF THE RESPIRATORY SYSTEM. 



DISEASES OF THE PULMONARY STRUCTURE. 

PSEUDOHYPERTROPHIC EMPHYSEMA. 

Synonyms. — Vesicular emphysema ; pulmonary emphy- 
sema. 

Two entirely different morbid conditions have been de- 
scribed under this name. Thus, where air escapes into the 
interstitial tissue, which may be due to rupture of lung sub- 
stance, the condition is sometimes termed surgical emphy- 
sema ; and a change associated with overdistention of the 
alveolar walls, an enlargement of the alveolar spaces of the 
lungs. The first form occurs in association with diseases 
in which there are violent paroxysms of coughing, injuries, 
and surgical interference. The second variety is the com- 
mon form known as pulmonary emphysema, which will be 
described. 



VESICULAR EMPHYSEMA. 

Etiology. — It may result from bronchitis, pertussis, or 
asthma, due to the violent attacks of coughing which occur in 
these conditions, and it may appear in individuals who give no 
such history. It is a common disease in advancing age, and 
it may take place as a senile change. Occupations requiring 
prolonged straining of the lungs, as glass-blowers, and blow- 
ing of wind instruments, may produce the disease. 

Occasionally the disease is met with early in life. Men are 
more frequently affected than women. 

Pathology. — The essential change in the lungs is the loss 
of elasticity from overdistention of the walls of the air vesicles, 
producing consequent weakening, with atrophy of the elastic 
tissue in the alveolar septa. The walls of the alveoli yield 
more and more to the pressure of the inclosed air, and be- 
come permanently distended, and similar processes take place 
in the adjacent alveoli, often the septa are destroyed, and 
two or more alveoli communicate. Not only the elastic tissue 
of the lung, but also the intra-alveolar capillary network is 
destroyed ; and if the process be extensive, great numbers of 
the air-spaces are enlarged and permanently distended, so that 
the elasticity of the lung, which is necessary for complete 



VESICULAR EMPHYSEMA. 39 1 

physiologic respiration, particularly expiration, is permanently 
reduced. 

The process is not always a primary one. It may develop 
as a result of other lesions, to which it is secondary. If for 
any cause disease of a certain portion of the lung occur, in 
which a lobule or lobe becomes incapacitated, the adjacent 
parts assume additional activity in taking upon themselves 
more work, the vesicles becoming distended and overexpanded, 
often causing them to lose their elasticity, and compensatory 
emphysema results. This compensatory form develops in the 
upper lobes when disease of the lower lobes occurs, or in one 
lung when the other lung is extensively diseased. It has 
also been called vicarious emphysema. 

The condition involving the greater part of both lungs, 
essential pulmonary emphysema or substantive emphysema, 
is the disease which will now be described. 

Upon postmortem examination, as the lungs are removed 
from the chest they do not collapse ; on the contrary, they 
may bulge out when the incision is made along the edge of 
the sternum. The alveolar structure is soft, downy, relaxed, 
inelastic, and pits upon pressure. The lung is gray in color, 
being almost bloodless. Bladder-like projections, which are 
composed of overdistended alveoli, are noticed, and collapse 
upon section. 

The upper portions of the lungs seem to be dry, while the 
dependent parts are moist from edema. 

Symptoms. — Cough and expectoration, usually due to the 
accompanying bronchitis, is present to some extent. Short- 
ness of breath is progressive, occurring first only upon exertion, 
but later appearing continuously. 

Bronchitis, bronchiectasis, dilatation and hypertrophy of the 
heart, especially of the right ventricle, and kidney disease are 
apt to be present. 

Physical Signs. — Inspection. — The appearance of the 
chest is characteristic, the inspiratory form in varying degrees 
being noted. The chest is broad, deep, and short ; the 
shoulders are raised ; the upper ribs are close together, and 
the lower ribs farther apart. The anteroposterior diameter, 
compared with the normal diameter, is increased, and the 
costal angle is obtuse. The nipple may be opposite the fifth 
rib, and the impulse of the heart often be seen in the sixth 
intercostal space, being pushed downward by the left lung. 
The impulse may be obscured on account of the overlap- 



392 DISEASES OF THE RESPIRATORY SYSTEM. 

ping of the lung interposing between the heart and the chest- 
wall. 

Palpation. — Palpation gives diminished vocal fremitus. 

Percussion. — The note is vesiculotympanitic or tympanitic. 
The liver is pushed downward, and liver dullness partly ob- 
scured. 

Auscultation. — The breath sounds are distant, indistinct, 
and scarcely audible, expiration being prolonged so that the 
normal ratio of inspiration and expiration may be reversed. 
Rales relating to the bronchitis actively associated are also 
heard all over the chest. 

Diagnosis. — The contour of the chest, the prolonged ex- 
piration, the feebleness of the breath-sounds, the dyspnea, 
the cough and history all make the diagnosis easy. 

Prognosis. — Recovery — that is to say, restoration to the 
original condition — does not occur in this disease, although 
the duration of life is usually prolonged. 

Treatment. — Treatment should be directed to the improve- 
ment of the general health and observance of proper hygiene. 
Attacks of bronchitis should be prevented if possible, as they 
may tend to add to the mechanical dilatation of the lungs 
from the cough. Where bronchitis is associated with a great 
deal of expectoration, the terebinthinates and balsams are of 
use. 

Expectorants, such as apomorphia, ipecac, and the ammo- 
nium salts, are often of especial value. If the cough becomes 
oppressive, opium or its derivatives may be used at short 
intervals with great caution. The iodids and strychnin are 
of use, and careful attention should be given to the heart, and 
the first signs of dilatation should be observed. When they 
occur, digitalis and caffein are of use. Inhalations of com- 
pressed air and expiration into rarefied air have been followed 
by good results in some instances. 

PULMONARY ATELECTASIS. 

There are two varieties— congenital and acquired. 

The congenital form occurs at birth, in which the lung of 
the new-born has never contained air. The acquired form 
occurs in the course of many diseases, being secondary. 

The lung is airless and collapsed. The lung tissue may 
not be altered at first, being merely a mechanical compression. 
After a certain time, however, inflammatory changes take 



PULMONARY ATELECTASIS. 393 

place. The lung tissue assumes the condition to which the 
term " splenization " has been applied, on account of its 
resemblance to splenic tissue. In the more advanced stages 
the congestion gives place to a dry state, which is spoken of 
as " carnification." A change also noted in advanced stages 
is the formation of fibrous connective tissue. The involved 
area sinks when placed in water, and does not crepitate. 

ATELECTASIS OF THE NEW-BORN. 

This condition is due to imperfect respiration. The lung 
prior to birth is in a state of atelectasis, being an airless 
structure. If at birth an insufficient quantity of air enters the 
lungs, they remain uninflated (atelectatic), and at the autopsy 
no inflammatory change is noticed, so that the lungs may be 
expanded by the blowpipe. 

ACQUIRED ATELECTASIS. 

This may occur in two ways — first, by plugging of the 
bronchus or bronchiole by means of a fibrinous exudate. This 
happens especially in the narrow bronchi of young children, 
so that no air enters the related vesicular structure upon 
inspiration, causing the vesicular structure to be cut off. The 
air in the area beyond the plugged bronchus disappears by 
absorption. Collapse of the vesicles takes place, giving rise 
to a circumscribed atelectasis. This condition is commonly 
found in the lungs of children dying from bronchopneumonia, 
especially if this be secondary to measles, whooping-cough or 
diphtheria. Weakened respiratory effort, besides the plugging 
of the bronchus, is an important factor in bringing about this 
change. The second cause is in compression of the lung, 
such as may result from pleural effusion, hydrothorax, and 
pneumothorax, where the lung tissue is compressed and 
forced together with resulting atelectasis. This is by far the 
most frequent cause. By means of the compression, air is 
squeezed out of the vesicle, and the site at which the pres- 
sure takes place becomes collapsed. 

Great enlargement of the heart may produce atelectasis. 
This may also occur from large pericardial effusion. A sim- 
ilar condition may arise from an aneurysm of the thoracic 
aorta. 

Atelectasis of the bases of the lung may be caused by 
upward pressure of the diaphragm, as is the case in abdominal 
tumors of various kinds. Deformity of the chest due to scoli- 



394 DISEASES OF THE RESPIRATORY SYSTEM. 

osis of a high grade gives rise to atelectasis corresponding 
to the convexity of the curvature. 

Symptoms. — The respiratory acts are labored and in- 
creased, being thoracic in type. There is an inspiratory con- 
traction of the bases of the chest. Upon percussion, a flat 
note is produced ; and upon auscultation bronchovesicular 
breathing, with moist rales. Often crepitant rales may occur 
in the vesicles which have collapsed. If the amount of the 
consolidated area be great, bronchial breathing may be noted. 

Prognosis. — This depends upon the ability to remove the 
cause. In the majority of instances it is unfavorable. 

Treatment. — The primary disease should be treated. The 
patient should be encouraged to take deep inspirations, and 
change of posture should be frequently and systematically 
practiced. Cold effusions of the chest are sometimes useful. 
Strychnin and inhalations of oxygen are beneficial. 

PULMONARY HEMORRHAGE. 

Two important varieties occur : First, bronchopulmonary 
hemorrhage, where the blood escapes into the bronchus and 
is expectorated ; and secondly, the condition known as pul- 
monary apoplexy, in which the bleeding takes place into the 
lung tissue and in the air-cells. This condition is important 
from a pathologic and clinical standpoint. 

Bronchopulmonary Hemorrhage ; Hemoptysis. — This 
condition is not necessarily a serious one, as it arises under 
many circumstances and occasionally in young persons appar- 
ently in good health. It may consist in bringing up a mouth- 
ful of blood, which may be followed by similar attacks for two 
or three days, then cease without ill effects. This is, how- 
ever, rare. 

In the majority of cases, hemoptysis is an early sign of 
pulmonary tuberculosis, occurring before physical signs 
appear — at least before they are well marked. Early in 
tuberculosis a bronchopneumonia appears, with inflammation 
of the terminal structures. If it occurs late in the course of 
pulmonary tuberculosis, it is often due to erosion of an arte- 
rial twig or a minute aneurysmal dilatation of a small artery 
in a cavity. It is apt to be copious, and may be fatal. 

Bronchopulmonary hemorrhage takes place in many acute 
and chronic diseases of the lung, occasionally in the initial 
stages of croupous pneumonia, where it must not be confused 



PULMONARY HEMORRHAGE. 395 

with the rusty sputum. It results from cancer of the lungs, 
in abscesses, in bronchiectasis, ulcerative lesions of bronchi, 
and rarely in acute bronchitis, in plethoric individuals, and fre- 
quently in diseases of the mitral valve. It may be the result 
of an aortic aneurysm. Malignant diseases and parasites are 
also causes. 

There is a form of hemoptysis described as vicarious hem- 
orrhage, occurring in women, in which the hemorrhage is 
supposed to take the place of the menstrual flow. It is 
probably an early sign of tubercular involvement, and not due 
to a vicarious menstruation. 

Pulmonary hemorrhage may occur in gouty persons, and it 
also occurs in the hemorrhagic diathesis, especially in various 
forms of purpura. Trauma to the chest-wall may be a cause. 

Symptoms. — As a rule, the attack begins suddenly, the 
patient experiencing a sensation of warmth and a salty taste 
in the mouth, followed by the expectoration of a quantity 
of bright red blood. Coughing is apt to follow, as the 
larger bronchial tubes and the trachea may contain blood. 
The quantity of blood expectorated varies from an ounce to 
several quarts. 

There may be bronchopulmonary hemorrhage without the 
appearance of blood, as when bleeding takes place into a 
large pulmonary cavity. Blood-spitting should not be mis- 
taken for blood coming from the stomach. 

As a rule, during the period of blood-spitting there is no 
fever, and if the hemorrhage be profuse subnormal tempera- 
ture may be present. The pulse is feeble and rapid. The 
skin may be cold and clammy and the expression anxious. 
Later, when the small clots are coughed up, a reactionary 
febrile movement, usually ranging from ioo° F. to 104 F., 
occurs. The previous history is important. The attacks 
are apt to recur for a few days, and after the last spitting of 
blood the sputum may be blood-stained for a day or so. This 
is followed by the appearance of small dark blood-clots. These 
are simply coagula which have formed at the time of blood 
spitting and undergone softening. It occasionally transpires 
that portions of the blood may be swallowed and vomited after 
a day or two. 

The chest should not be examined by the means of physical 
methods, as the thrombus which has formed in the vessel and 
prevents the hemorrhage may be dislodged, and the bleeding 
start anew. 



396 DISEASES OF THE RESPIRATORY SYSTEM. 

Differential Diagnosis. — 

Hemoptysis. Hematemesis. 

Blood is bright red and frothy ; often Blood is dark, clotted, and often mixed 
coughed up. with food ; is vomited. Stools may 

be tarry. 

Alkaline in reaction. Acid in reaction. 

Containing air-bubbles. Air-bubbles absent. 

Tubercle bacilli may be present in the No tubercle bacilli in the blood, 
blood. 

Prognosis. — In the early blood-spitting due to tuberculosis 
recovery from the hemoptysis is the rule. The later hem- 
orrhage in phthisis, such as occurs into the large cavity, is apt 
to be fatal. 

Pulmonary Apoplexy. — Synonym. — Hemorrhagic infarct. 

This occurs when blood is effused into the tissues of the 
lung and the air-cells. As a rule, the process is not diffused, 
although occasionally it may be extensive. The infarct may be 
single or multiple. Its most common situation is the lower lobe 
of the right lung. It results from the blocking of a blood-ves- 
sel by a thrombus or embolus. It is most often located at the 
periphery of the lung, and is wedge-shaped, the apex of the 
wedge being at the point of the blocking of the artery, and the 
base toward the pleura. Occasionally the infarct is not wedge- 
shaped, but irregularly oval, occurring in the substance of the 
lung, looking like a recent blood-clot. The overlying pleura 
is mostly involved so that a plastic pleurisy results. The in- 
farct is firm, airless, and the surface raised if situated super- 
ficially. On section it is bluish or brownish-red in color and 
somewhat granular, and microscopically the infarct contains 
leukocytes and many red corpuscles infiltrated into the tissues 
and fibrin. The infarct may undergo subsequent changes. 
It may be absorbed (if not too large), or, if infected, abscess 
or gangrene may develop. A cyst or scar tissue may replace 
the area. It is sometimes possible to find the obstruction 
which has caused the blocking. 

Emboli may result from right-sided heart lesions or from 
the breaking up of a thrombus in the peripheral veins, reach- 
ing the right side of the heart, and enter the pulmonary 
artery. Rarely thrombosis of the pulmonary artery, due 
often to sluggish circulation from valvular disease of the heart 
and weakened muscle, is a cause of pulmonary apoplexy. 
It is more common in men than in women. It is more com- 
mon between the ages of fifteen and thirty-five, and is rare in 
the extremes of life. 



BRONCHOPNEUMONIA. 397 

Symptoms. — The clinical phenomena are not definite. 
There may be a chill, dyspnea, pain in the side, and uncon- 
sciousness, and often death. Upon examination, dullness upon 
percussion and a friction sound may be present. 

Treatment of Pulmonary Hemorrhage. — The patient 
should be put to bed and absolute bodily and mental rest en- 
joined. No food, and especially no fluids, should be admin- 
istered. Ice-bags may be placed upon the chest. The hem- 
orrhage ceases by the formation of a thrombus in the affected 
region, and the formation of this thrombus can best be 
attained by lowering blood pressure and the administration 
of opium or its derivatives. If the heart's action is tumultu- 
ous, small doses of tincture of aconite may be given. The 
administration of salt is useless, and only increases the thirst. 
All measures which are of advantage in internal bleeding are 
of use in this condition. Systematic purging is often good 
practice. 

BRONCHOPNEUMONIA. 

Synonyms. — Lobular pneumonia ; catarrhal pneumonia ; 
capillary bronchitis. 

Definition. — This disease is in the majority of instances 
a secondary affection, following bronchitis. The inflammatory 
process, from continuity of structure, proceeds from the large 
bronchial tubes into the finer ones, and finally affects the vesic- 
ular structure of the lungs. 

Etiology. — It occurs most frequently in the extremes of 
life, infants and the aged being most subject to the affection. 
According to Aufrecht, scrofula and rickets predispose. The 
infectious diseases, especially those that are accompanied by 
bronchitis, such as measles, pertussis, influenza, diphtheria, 
enteric fever, etc., are likely to produce the disease, especially 
when the vital forces are greatly lowered. Most cases develop 
in the winter and spring months. 

In many severe acute and even in chronic diseases the 
malady is apt to occur. In some instances, foreign material, 
sputum, and particles of food are likely to find their way into 
the trachea, and set up inflammatory changes which rapidly 
infect the finer bronchi and alveoli, thus producing broncho- 
pneumonia. This condition is called inhalation, insufflation or 
deglutition pneumonia. It is likely to happen in the low fevers 
and in diseases characterized by the so-called " typhoid state." 

Micro-organisms of various kinds, pneumococcus, strepto- 



398 DISEASES OF THE RESPIRATORY SYSTEM. 

coccus, staphylococcus, Klebs-Loffler bacillus, bacillus of 
influenza, bacillus of tuberculosis, and others, may find their 
way into the lobules and give rise to the affection. 

Pathology. — The pathologic changes are chiefly those 
encountered in catarrhal inflammations. Consolidated masses 
of various sizes and shapes are found in different parts of the 
lungs. This frequently happens in pulmonary tuberculosis, 
in which case the tubercle bacillus is the excitant. 

The lungs are seen to be distended and injected, and do not 
collapse readily. Rounded areas of red patches, slightly ele- 
vated, may be seen beneath the pleura. The pleura is often 
opaque and covered with a delicate fibrinous material, but this 
is absent in many cases. Masses of various sizes may be felt 
in the lung substance. On section of the lung the nodules 
are flattened, or of a reddish-gray or dark red color. Upon 
pressure a small amount of yellow viscid fluid escapes. The 
bronchi are filled with an inflammatory exudate, or sometimes 
with the foreign material which has caused the condition. 

Surrounding the nodules the lung tissue is often emphyse- 
matous, and here or there may be seen collapsed areas (ate- 
lectasis). Both lungs are usually involved in the process, 
and any part of the lung is liable to be affected. 

The smaller and medium-sized bronchi are the seat of a 
catarrhal inflammation and filled with a mucopurulent exudate 
which may be squeezed out. The lung crepitates in most 
parts, and floats when placed in water ; the consolidated areas, 
when excised and thrown in water, sink. 

Microscopically, the terminal bronchi and alveoli show 
varying quantities of mucous exudate mixed with epithelial 
cells, leukocytes, few red blood-cells, and little if any fibrin. 
The blood-vessels are dilated, and the lung structure is infil- 
trated with leukocytes. 

Symptoms. — Primary Form. — In rare instances broncho- 
pneumonia begins as an acute primary affection with the 
symptoms of a severe bronchitis. The patient has malaise, 
cough, dyspnea, and pain. Fever may range between 102 
and 103 F. The expectoration is not characteristic, but often 
the ordinary mucopurulent variety, never mixed with blood, 
or rusty. The physical examination shows rales, broncho- 
vesicular breathing, and small areas of consolidation in both 
lungs, surrounded by tympanitic areas. The affection may 
last two or three weeks, the disease ending by lysis, and never 
by crisis. 



BRONCHOPNEUMONIA. 399 

Secondary Form. — The onset of the disease is gradual, 
the early symptoms being those of the preceding bronchitis. 
Symptoms which call attention to the fact that bronchopneu- 
monia has developed are a rise in the temperature to 104 F. or 
105 ° F., increased dyspnea, rapid, feeble, running pulse, cough 
becoming more difficult, development of cyanosis, and a change 
in the physical signs. 

The respiration, especially in children, is from 60 to 80 per 
minute. This is accompanied by painful cough. In very 
young children there is no expectoration, and even where the 
sputum is present it is not characteristic. The patient is rest- 
less, apathetic, and frequently slightly somnolent. 

The pulse is extremely rapid, reaching a frequency of from 
140 to 160 per minute. Fever is always present, and usually 
high, from 103 F. to 105 ° F., but the temperature curve is 
not typical. 

Physical Signs. — Inspection. — Upon inspection, increased 
respiratory effort will be noticed upon both sides of the chest, 
also some slight cyanosis. 

Palpation. — This may develop limited areas of increased 
vocal fremitus. 

Percussion. — Upon percussion, small areas of dullness, 
surrounded by limited tympanitic area in both lungs, espe- 
cially posteriorly, will be noted. 

Auscultation. — The most typical signs are present upon 
auscultation. Bronchovesicular breathing and fine moist rales, 
most often subcrepitant in character, are diffused over the 
chest. To these will be joined the rales of the accompanying 
bronchitis of the larger tubes. 

Complications and Sequels. — The course of the disease is 
slow r . In cases that terminate favorably it lasts from three to 
four weeks, often longer, during which time remissions and 
exacerbations are apt to occur. 

The disease may terminate in tuberculosis ; especially is 
this apt to occur when the bronchopneumonia takes place 
during the course of pertussis or measles. 

Occasionally abscesses and gangrene of the lung follows. 
Should the pleura become involved, signs of the pleurisy, 
with or without effusion, and occasionally even empyema may 
develop. It may sometimes be followed by chronic inter- 
stitial pneumonia. 

Diagnosis. — As a rule the diagnosis is not difficult. The 
persisting bronchitis, with a sudden rise in temperature, in- 



400 DISEASES OF THE RESPIRATORY SYSTEM. 

creased respirations, and the physical signs, usually determine 
the diagnosis. The disease must, however, be differentiated 
from croupous pneumonia, which it may resemble in some 
degree. 

Differential Diagnosis. — 

Bronchopneumonia. Croupous Pneumonia. 

The disease is secondary following A primary affection, beginning sud- 

bronchitis, and begins gradually. denly, often with marked chill. 

A bilateral disease. Most often unilateral. 

Temperature not typical. Typical temperature. 

Prolonged disease ending by lysis. Short affection, ending by crisis. 

Affecting lobules in both lungs. Affecting one or more lobes of the lung. 

Sputum not characteristic ; no herpes. Sputum rusty ; herpes common. 

Subcrepitant rales ; bronchovesicular In first stage, crepitant rales ; second 

breathing. stage, bronchial breathing ; third 

stage, crepitus redux. 

Prognosis. — Bronchopneumonia is always a serious affec- 
tion. In children under two years, 50 per cent, of the cases 
are fatal ; under five years, one-fourth of the number of chil- 
dren affected die. It is equally serious in the aged. The 
disease is extremely rare during the middle periods of life. 

Treatment. — The prophylaxis is most important. A child 
affected with acute bronchitis should be carefully guarded, and 
the possibility kept in mind that the case may develop into 
bronchopneumonia. Proper attention should be given to 
slight nasal catarrh and mild coughs. 

In the treatment of bronchopneumonia itself, when the tem- 
perature becomes high, cyanosis shows itself, and somnolence 
is threatened, a warm bath with cold effusions to the head is 
useful. When the pulse becomes weak, alcohol is indicated. 
The application of ice poultices, sinapisms, and turpentine stupes 
to the chest is of benefit. Bleeding is not indicated. Inhalations 
of steam that has been medicated by compound tincture of 
benzoin or camphorated tincture of opium are useful. In 
strong children in whom there is great secretion in the bron- 
chial tube, which is with difficulty brought up, emetics should 
be used from time to time, but these should not be continued 
throughout the course of the disease. Narcotics should not 
be administered to very young children. Stimulating expec- 
torants, such as the salts of ammonia, are often useful. 
Minute doses of strychnin and inhalations of oxygen are of 
benefit. A mild purge at the onset frequently gives great 
relief. The diet should be a light, nutritious one. 



CHRONIC FIBROID PNEUMONIA. 40 1 



CHRONIC FIBROID PNEUMONIA. 

Synonym. — Cirrhosis of the lung. 

Definition. — This occurs under a variety of circumstances 
in which there is an extensive formation of fibrous tissue in 
the lung, extending from the bronchi and blood-vessels, the 
pleural covering, and interlobular tissue. It is usually the 
result of a secondary process, and may be either localized or 
diffused. 

Etiology. — A localized formation of cicatricial tissue re- 
places destruction of lung which may be occasioned by abscess, 
gangrene, injury, etc. 

The encroachment by parasites which have encysted them- 
selves, abscesses, tubercles, gummata, aneurysms, and tumors, 
are often prevented from spreading or checked by fibrous tissue 
in their immediate vicinity. This condition is then more often 
beneficial than injurious. It often occurs during the course of 
chronic bronchitis, the growth of fibrous tissue extending into 
the lung from the bronchial walls. Dilatation of the bronchi, 
obliteration of the bronchioles, and emphysema are often asso- 
ciated. 

Tuberculosis, syphilis, croupous and bronchopneumonia, 
and the inhalation of fine particles of coal dust, limestone, 
chalk, silica, and iron may give rise to cirrhosis of the lung. 

Pathology. — It is most frequently a unilateral disease, 
sometimes bilateral, and often localized to small areas. The 
involved lung is much contracted, dense, heavy, and very 
tough, and offers great resistance to the knife. The surface of 
the lung is irregularly nodular. 

The pleura is usually greatly thickened, revealing the same 
general pathologic process. The adjacent organs, heart, op- 
posite lung, and liver, are displaced. 

Upon section the cut surface presents a smooth appearance, 
and the color is grayish-red ; a yellow fluid exudes. The lung 
may be pigmented, depending upon the character of the irri- 
tant. Microscopically, a great increase in fibrous connective 
tissue will be noticed, in some instances so profuse that the 
alveolar structure has entirely disappeared. The new-formed 
connective tissue is in some instances marked about the bron- 
chi, in others around the blood-vessels, or may extend from 
the pleura. From the narrowing and destruction of numerous 
blood-vessels, during the course of their change, the flow 
26 



402 DISEASES OF THE RESPIRATORY SYSTEM. 

of the blood through the lung is impeded, giving rise to 
hypertrophy and dilatation of the right heart. 

Compensatory emphysema of the unaffected lung is a 
natural sequel. Pericarditis may occur during the course of 
the process. 

Symptoms. — The disease frequently begins as an ordinary 
acute pneumonia, terminating either by crisis or lysis. Occa- 
sionally, a subfebrile temperature may remain for several weeks. 
Dyspnea and cough continue, and the sputum becomes muco- 
purulent. If the case does not terminate fatally, the fever 
subsides, the cough lessens, and the patient improves, but a 
retraction of the affected side of the chest takes place, which 
remains permanently. Cough, dyspnea, cyanosis, and edema 
are likely to follow from the affection of the right heart. A 
similar condition has been described as the result of congeni- 
tal syphilis, involving both lungs. 

Physical Signs. — Inspection. — The heart is displaced and 
drawn toward the affected side. Compensatory emphysema 
is usually noted upon the healthy side. The diseased side of 
the chest is retracted ; the intercostal spaces are almost oblit- 
erated by the ribs coming closer together. 

Palpation. — Respiratory movement is restricted upon the 
affected side. The vocal fremitus is usually increased except 
when the pleura is greatly thickened, when it may be absent 
altogether. 

Percussion. — Great differences of the note are elicited upon 
percussion. Most often there is dullness and even flatness, 
but a tympanitic note may be elicited if there is a dilated 
bronchus in the retracted area. 

Auscultation. — The breath-sounds are distant and feeble. 
Bronchovesicular and even distant bronchial breathing may 
occur. All kinds of moist and dry rales are heard, often 
accompanied by some friction sounds. 

Diagnosis. — Early the disease can not be differentiated 
from the delayed resolution occurring from croupous pneu- 
monia. Only when retraction of the chest takes place can 
the condition be diagnosticated. 

Prognosis. — The prognosis as to life is favorable, but the 
condition is incurable. The patient is very liable to recurring 
attacks of bronchitis, and bronchiectasis is very apt to arise. 
Death often results from failure of the right heart. 

Treatment.- — A nutritious diet is important. The patient 
should have the best and most substantial food. The resi- 



CONGESTION OF THE LUNGS. 403 

dence in a high and dry altitude is of great use, otherwise 
the treatment is symptomatic. Tonics are often useful. 



CONGESTION OF THE LUNGS* 

There are two varieties of this condition : Active and passive. 

Active Congestion. 

Hyperemia or active congestion occurs from increased 
action of the heart, inhalation of irritating chemic substances, 
heated air, dust, etc. Obstruction to the blood-current in one 
lung often causes more blood to be driven into the other 
lung, giving rise to active congestion. Hyperemia occurs 
in pneumonia, pleurisy, pressure from tumors, and like 
conditions. 

It may arise from exposure to extreme heat or cold, espe- 
cially after exertion, such as public speaking under great ex- 
citement, undergoing violent exertion, passing from a heated 
and close auditorium into the cold air. 

The involved area is dark red in color, heavier than normal, 
but floats when placed in water. Upon section blood drips 
from the cut surface. Some of the alveoli may contain blood. 

Symptoms. — These are by no means well defined. There 
may be chill followed by fever, the temperature rising to 
10 1 ° F. or 103 F., with cough, dyspnea, and pain in the side. 
The physical signs may show enfeebled respirations, impair- 
ment of resonance, and fine moist rales. It frequently termi- 
nates fatally. 

Passive Congestion. 

Passive congestion is subdivided into (a) mechanical, (b) 
hypostatic. 

Mechanical passive congestion occurs where there is an 
obstacle to the return of the blood, as in valvular disease and 
myocarditis, the disturbance of blood-pressure resulting in the 
accumulation of blood in the lungs. Tumors of the medias- 
tinal tissues may interfere with the circulation. When the 
congestion has persisted for some time, brown induration of 
the lung results. 

If due to cardiac disease, no symptoms appear so long as 
compensation is maintained, but with rupture of compensation, 
symptoms of cough, dyspnea, expectoration, and sometimes 
hemoptysis appear. 



404 DISEASES OF THE RESPIRATORY SYSTEM. 

Hypostatic congestion occurs in adynamic conditions, espe- 
cially in the low fevers. The bases of the lungs become 
deeply congested, partly from the action of gravity and partly 
due to the enfeebled circulation, causing the blood to accumu- 
late in the bases posteriorly. The lung is dark red in color and 
engorged with blood ; some portions of it may be atelectatic, 
and may sink when thrown into water. This condition has 
been termed " hypostatic pneumonia." 

Treatment. — The treatment consists in removing the under- 
lying causes if possible. In active congestion free bleeding is 
often of great value. 

PULMONARY EDEMA. 

Transudation of the watery elements of the blood through 
the walls of the blood-vessels into the alveoli, often the 
bronchi and interstitial tissues of the lungs, gives rise to 
what is termed "pulmonary edema." 

The edema may be general or local. 

General Edema. — All causes which give rise to active and 
passive congestion may produce edema. It is frequently the 
terminal event in many chronic affections, especially cardiac, 
renal, pulmonary, and cerebral diseases, also from the cachex- 
ias and anemias. 

Local edema may result from local disturbance of the 
blood supply, as infarcts, tumors, etc;, also from inflammatory 
conditions. 

Pathology. — The edematous lung is heavier than the normal, 
but floats when placed in water. Crepitation is elicited. The 
color of the lung varies, depending upon the causation ; if 
resulting from renal disease, it is often of the normal color ; 
when from congestion, it is dark red. Upon section serum 
escapes from the cut surface ; this may be frothy or bloody. 
(The lung is spoken of as being " water-logged.") The edema 
is most marked in the dependent portions. The general factors 
concerned in the development of edema are disturbance in the 
blood pressure, change of the blood composition, and changes 
in the vessel walls. 

Symptoms. — As the condition is usually secondary, an 
aggravation of the existing symptoms of the disease takes 
place. The dyspnea increases ; the cough becomes more 
urgent and troublesome ; large numbers of moist rales of all 
sizes are heard, particularly at the bases of the lungs ; and 



ABSCESS OF THE LUNG. 405 

the tracheal rale, known as the V death-rattle," is in evidence 
in those terminating fatally. 

Treatment. — The treatment is that of the primary disease. 
There should be active purging, especially if cyanosis be 
absent. Hypodermics of atropia in large doses frequently 
repeated have been found of use in some cases. 

GANGRENE OF THE LUNG, 

All conditions which lead to abscesses may lead to gangrene, 
where necrotic areas are followed by putrefaction. It occurs 
in diabetes mellitus, pneumonia, from new growths, infarcts, 
and from septic emboli. The condition is found more com- 
monly in the lower lobe. It appears in debilitated subjects, 
and frequently after aspiration pneumonia. 

Pathology. — The appearance of gangrene is characteristic. 
The lung is softened and diffluent, and of a dirty grayish- 
black color. The odor of the lung is very foul and of a 
penetrating character. An inflammatory process is always 
found around the area of gangrene. 

Symptoms. — Cough accompanied by expectoration, which 
is abundant, thin, and foul-smelling, should call attention to 
gangrene of the lung. Fever is always present, the patient 
lying upon the affected side. There is often hemoptysis. 
The sputum, upon standing, collects into three layers — a top 
layer, which consists of mucopurulent material ; a middle 
layer, which is thin and watery ; and a lower layer, which 
consists of pus with greenish threads in it. Microscopically, 
leukocytes, shreds of lung tissue, especially elastic fibers, fat 
crystals, and bacteria are present. 

Upon percussion over the affected area dullness is usually 
present. Upon auscultation there is bronchial breathing, and 
if excavation occur, signs of cavity will be noted. 

Prognosis. — The prognosis is very unfavorable. 

Treatment. — The treatment is expectant symptomatic. 

ABSCESS OF THE LUNG, 

Abscesses may result during the course of pyemia, and may 
follow broncho- and croupous pneumonia ; they may result 
by extension, as from abscess of the liver, subphrenic abscess, 
and empyema. Abscess also frequently accompanies chronic 
tuberculosis. Trauma and the introduction of foreign bodies 



406 DISEASES OF THE RESPIRATORY SYSTEM. 

may sometimes give rise to the conditions. Carcinoma in 
which ulceration exists may give rise to marked suppuration 
of the lung. 

The abscesses vary greatly as to size and distribution. 

The Friedlander bacillus, diplococcus of pneumonia, staphyl- 
ococcus, bacillus of influenza, and streptococcus are the most 
common micro-organisms that have been found in the pus. 

Symptoms. — These are not characteristic. The history 
must be taken into account. Fever of the septic type is 
present. The physical signs of a cavity are usually noted. 
Often there is expectoration of pus, which is foul-smelling, 
and under the microscope contains elastic fibers. Leukocy- 
tosis is present in nearly all such cases. If the condition affect 
the pleura, the signs of pleuritis will be observed. 

Prognosis. — Is always guarded. In simple abscesses it 
may be favorable ; in embolic abscesses it is always grave. 

Treatment. — The treatment should be supportive. If the 
abscess is accessible, surgical interference is necessary. 



PNEUMONOKONIOSIS, 

Definition. — A disease of the lungs due to the inhalation of 
particles of dust, often followed by fibroid changes. 

Etiology. — Occupations which expose the individual to the 
inhalation of dust particles, such as coal-mining, stone-cutting, 
knife-grinding, and the work of millers predispose to the dis- 
ease. 

Pathology. — In the inhalation of dust particles, irritation is 
first set up in the epithelial lining of the bronchi, producing a 
catarrhal inflammation which is usually chronic. Later the 
dust particles are deposited in the lymphatic spaces of the lung, 
a proliferation of the connective-tissue cells results, and 
finally fibrous tissue forms, giving rise to interstitial pneu- 
monia. 

In this new-formed tissue the particles are held. In the 
case of coal dust, the lung is black ; if due to chalk or lime- 
stone it is of a light-gray color. 

The lung usually shows diffuse involvement, but the infiltra- 
tion may be more localized in some instances. The bronchial 
lymphatic glands almost invariably show infiltration. The 
lungs are usually increased in weight, especially so in anthra- 
cosis. Crepitation is commonly present throughout. In some 



SYPHILIS OF THE LUNGS. 407 

instances marked interstitial changes are present, the alveolar 
and bronchial tissues being replaced by the new formation. 

Infection may occur under these conditions by various 
micro-organisms, particularly by the tubercle bacillus. Ab- 
scess sometimes results. The pleura are usually thick- 
ened. Emphysema may follow, and bronchitis is generally 
present. 

Varieties. — (i) Anthracosis. — This condition is due to the 
inhalation of particles of coal, and is sometimes called " miners' 
phthisis." (2) Siderosis. — This condition is due to the inha- 
lation of particles of metal, especially fine steel. It is present 
in knife-grinders or in those exposed to the inhalation of small 
fragments of steel and of iron. It has been called " knife- 
grinders' phthisis," and the average duration of life in persons 
affected with this form of pneumonokoniosis is about six years. 
(3) Chalicosis. — This is due to the inhalation of small mineral 
particles, and occurs in occupations involving the chipping of 
minerals, such as millstones, etc. (4) Millers' Phthisis. — 
This is found in occupations in which cereals are ground. 

Symptoms. — The symptoms come on very gradually after 
many months or even years, first characterized by a more or 
less well-defined bronchitis. This may be followed by the 
development of an interstitial pneumonia, or the occurrence 
of tuberculosis. The sputum often contains the particles in- 
haled, as well as such characteristics encountered in the spu- 
tum of chronic bronchitis. 

Diagnosis. — The diagnosis depends upon the occupation 
of the patient, the gradually failing health, the condition of 
the sputum, and sometimes signs of consolidation, especially 
at the apex. 

Prognosis. — The prognosis depends upon the ability of the 
patient to change his occupation. If the disease be not too 
far advanced, cure may result. 

Treatment. — Prophylaxis consists in means devised to 
arrest the inhalation of dust particles. The treatment of the 
disease rests upon general principles. 

SYPHILIS OF THE LUNGS* 

Definition. — Syphilis of the lungs occurs in two forms : 
(7) The congenital form ; (2) the acquired form. The acquired 
form is associated with the formation of gummata, and some- 
times sclerotic changes. 



408 DISEASES OF THE RESPIRATORY SYSTEM. 

i. Congenital Syphilis. — This shows itself in the form to 
which the name pneumonia alba, or . white pneumonia, has 
been given. On section the lung is light-gray, nearly white 
in color, and almost completely airless. 

Microscopically there is wide-spread round-cell and spindle- 
cell infiltration, and fully developed connective tissue in the 
interalveolar and interlobular substance, with more or less 
compression of the bronchioles and alveoli. Some of the 
cells contain numerous fat drops, the structure having 
undergone fatty degeneration. When pneumonia alba is 
present, the child is either born dead or dies shortly after 
birth. The symptoms are indefinite, although consolida- 
tion may be revealed upon examination. Evidences of 
syphilis in other parts of the body will be found. Clinically, 
white pneumonia can not be differentiated from bronchopneu- 
monia. 

2. Acquired Syphilis. 

Pathology. — Changes in the lung are due to the formation 
of gummata, usually accompanied by diffuse interstitial lesions. 
The gummata are always characteristic, but the condition is ex- 
tremely rare. They occur in the form of firm nodules, vary- 
ing in size from a pea to a large apple, with a pale yellow 
cheesy center of firm consistency, surrounded by a translu- 
cent, grayish tissue, ending in an area of injected lung sub- 
stance. The gummata are likely to appear near the root of 
the lung, often connected with the bronchi ; in this way symp- 
toms of pressure occur. If there are no symptoms of pres- 
sure, the condition can not be diagnosticated. Secondary 
changes which may be of syphilitic origin are interstitial 
changes, due to the growth of dense connective tissue. The 
connective tissue may also form in the bronchial wall and 
peribronchial tissue, producing nodular masses. In this con- 
nection bronchopneumonia may result. Sclerotic changes of 
the blood-vessel walls are also present. 

Symptoms. — In symptoms referable to the respiratory 
organs, in the person suffering from acquired syphilis, when 
other diseased conditions can be* eliminated, syphilis of the 
lung should be suspected. The most common symptom is 
dyspnea, increased by exertion and becoming worse as the 
disease progresses. Cough is present, usually with mucopu- 
rulent expectoration. 

Physical Signs. — The physical signs are those of stenosis 
of the bronchial tube, or bronchiectasis, or similar signs due 



NEW GROWTHS OF THE LUNGS. 4O9 

to profound bronchitis or bronchopneumonia. The physical 
signs, as a rule, are obscure. 

Prognosis. — The prognosis is unfavorable. 

Treatment. — The treatment is that of syphilis in general — 
mercury and iodid of potassium. 



NEW GROWTHS OF THE LUNG. 

New growths of the lung are rarely primary ; they are most 
often secondary, the evidences of primary growth being found 
elsewhere in the body, and being transferred by means of the 
blood or lymphatics. 

Primary Tumors. — Of the benign connective-tissue tumors, 
fibromata, lipomata, and chondromata have been observed, but 
they are rare. Of the epithelial benign tumors, adenomata have 
been recorded. Of the embryonic connective-tissue tumors, 
various sarcomata have been found, but are usually secondary. 

Carcinomata as primary growths have also been found ; these 
are usually massive growths situated at the base of the lung. 
They show a tendency to ulceration and degeneration (as is 
common in carcinoma). They may be of the cylindric variety, 
or if they spring from the squamous epithelium of the alveoli, 
are of that type. The neighboring lymphatic glands are 
involved. 

Secondary Tumors. — Secondary tumors are more common 
in sarcoma than in carcinoma. 

Symptoms. — The symptoms are those of pressure, the 
patient complaining of dyspnea, cough, and expectoration ; 
and occasionally hemoptysis occurs. There may be difficulty 
in swallowing, due to pressure upon the esophagus, or the 
mass may press upon the recurrent laryngeal nerve, causing 
paralysis of the vocal cords. 

When there is sharp stitch-like pain, the pleura is involved. 
Pliysical examination may reveal bulging of the affected side, 
due to the growth. 

Percussion gives flatness, and auscultation shows absence of 
breath-sounds. Enlargement of the glands in the axilla in 
case of carcinoma and dilatation of the veins of the neck are 
of value in diagnosis. 

Prognosis. — The duration of the disease is from one-half a 
year to a year and a half in cases of the malignant tumors. 

Treatment. — The treatment is symptomatic. 



4IO DISEASES OF THE RESPIRATORY SYSTEM. 



PARASITES, 

The echinococcus or hydatid cyst occasionally appears in 
the lung. It usually represents the extension from the liver, 
the cyst having ruptured through the diaphragm. Cough 
and hemoptysis are sometimes present ; however, the signs 
and symptoms are not characteristic. 



DISEASES OF THE PLEURA. 
PLEURISY. 

Definition. — Pleurisy is an inflammation of the whole or 
a part of the pleura. The condition may be either acute or 
chronic. 

The disease may be classified into dry or adhesive, and 
pleurisy with effusion. Pathologically the disease may be 
classified into fibrinous, serofibrinous, purulent inflammation, 
and fibrous or clironic pleurisy. 

The disease may be primary or secondary. The clinical 
classification is divided into the acute and the chronic forms. 

DRY, FIBRINOUS OR PLASTIC PLEURISY. 

Etiology. — The condition is often the result of prolonged 
exposure to cold. It may often occur in the rheumatic diathe- 
sis, in many of the infectious diseases, and in rare instances may 
be due to syphilis. Traumatism is also a prominent cause. 

In the majority of instances the disease is secondary, due 
to some affection of the lung, one of the principal causes 
being pulmonary tuberculosis ; next in frequency, croupous 
pneumonia and infarcts of the lung. It occasionally occurs 
in connection with pericarditis. 

Pathology. — The pleura is usually involved to a limited 
extent, although the entire area may be affected. The earliest 
change noted is a reddening of the surface. The pleura loses 
its luster, becomes rough and dry, and later the fibrinous ex- 
udate will be formed upon the surface, which varies greatly 
as to extent and thickness. The visceral and parietal layers 
may become temporarily adherent as a result. The earliest 
change is hyperemia, followed by the migration of leukocytes 



PLEURISY. 4 I I 

and the pouring out of liquor sanguinis, which finds its way to 
the free surface, where fibrin is formed. This results from the 
action of some ferment upon the fibrinogen of the blood. 
There is also a proliferation of the fixed connective-tissue cells 
of the part, and red blood-cells may be found in the peri- 
vascular tissues. The endothelial cells show granular degen- 
eration early in the stage of inflammation, and reveal desqua- 
mation. 

Fibrinous pleurisy frequently terminates in pleurisy with 
adhesions. When the exudate is well formed, both surfaces 
of the pleura may be adherent, and in this framework of fibrin 
new blood-vessels appear, springing from the visceral and 
parietal layers. Connective-tissue cells proliferate in this 
area ; they elongate, forming fibroblasts, and finally fully 
formed connective tissue is developed, the fibrin being ab- 
sorbed in the greatest number of instances. This results 
in the formation of permanent adhesions. Whether the ex- 
udate is ever completely absorbed, leaving the serous mem- 
brane in a healthy condition, is doubtful. 

Symptoms. — The disease may either come on acutely or 
insidiously. The acute form begins with sharp, shooting pain 
upon the affected side. Occasionally, however, the pain is 
felt in the abdomen, and even upon the opposite side. A 
chill rarely occurs. There is slight fever, the temperature 
ranging from ioo° F. to 102 F. This fever soon declines, 
often reaching the normal upon the second day and remaining 
so throughout the course of the affection. 

The respirations are slightly increased in number, and there 
may be a dry cough, which the patient endeavors to suppress. 
The pain itself rarely lasts longer than one or two days, 
giving place to a feeling of soreness upon the affected side. 
The majority of such cases terminate in speedy recovery. 

The disease may have a tendency to recur, or if it begins 
gradually, great pleural thickening develops without pain. 
The greater number of such cases are tubercular in origin. 
The symptoms in this form are mild, although this is not in- 
variably the case. 

Physical Signs. — Upon inspection the respiratory excurses 
upon the affected side may be decreased. Occasionally upon 
palpation the friction fremitus is felt. There is no change 
from the normal on percussion. The important sign is the 
friction sound which is heard upon auscultation. It is described 
as a grazing, rubbing or rasping sound, sometimes resembling 



412 DISEASES OF THE RESPIRATORY SYSTEM. 

the creaking of new leather. It is heard either with inspira- 
tion and expiration or both, and is not affected by cough. It 
may be increased by pressure of the stethoscope. The friction 
sound bears no relation to the presence of pain. There may 
be wide areas of friction with little or no pain. 

Pleuropericardial Friction. — If the pleurisy occur upon 
the left side, a friction sound may be heard which is synchro- 
nous with the beat of the heart. This is due to the rubbing 
of the pericardial sac against the roughened pleura, and can 
be distinguished from ordinary pericardial friction by being 
increased at the height of inspiration and by its limitation to 
the left border of the pericardial area. 

Diagnosis. — The diagnosis depends upon the sudden on- 
set with pain, slight fever, and presence of a friction sound upon 
auscultation. 

Differential Diagnosis. — 

Plastic Pleurisy. Intercostal Neuralgia. 

Pain somewhat diffused, not limited to Pain particularly localized to the exit of 

a certain area. the intercostal nerves. 

Slight fever and cough. No fever and no cough. 

Herpes absent. Herpes in the affected area common. 

Friction sounds present. No friction sounds. 

SEROFIBRINOUS PLEURISY. 

Synonym. — Pleurisy with effusion. 

Etiology. — In the present state of knowledge, it is safe to 
say that the majority of primary pleural effusions are tuber- 
cular in origin. Cold and exposure, especially exposure to a 
chilly, moist atmosphere, may be considered as the predis- 
posing causes, although some authorities entirely deny the 
etiologic influence of cold. 

Other conditions which cause pleural effusion are croupous 
pneumonia, the pneumococcus being found in serofibrinous 
effusions. Acute rheumatic fever is sometimes accompanied 
by pleural effusion. It may occur in the course of syphilis. 
In enteric fever pleural effusions take place, and in the infec- 
tious diseases of childhood the condition is not uncommon, 
although in the greater number of these cases the effusion is 
likely to be purulent in character. Traumatism must also be 
given a place in the etiology. Secondary pleural effusions 
sometimes occur as the terminal event in chronic diseases of 
the heart and kidney. 

In aneurysms, new growths, abscesses, and hydatids of the 
liver, peritonitis, and in ovarian cysts, serofibrinous pleurisy 



PLEURISY. 4I3 

may develop. The condition is most common between the 
twentieth and the fortieth years, but it also occurs in infancy. 
It is perhaps somewhat more frequent in men than in women. 
The disease is more prevalent in the cold season. 

Pathology. — Serofibrinous pleurisy may be the further 
development of the dry stage, although in many instances it 
begins at once as a serous exudation. The liquid exudate is 
heavier than the fluids found in transudates, and it contains 
flakes or shreds of fibrin. The specific gravity of the exudate 
is usually above 10 18, in transudates being below this. 

The character of the exudate is pale yellow, sometimes 
brownish yellow, transparent, and is occasionally a slightly 
opaque, odorless fluid. A quantity of fibrin is usually sus- 
pended in it, which may coagulate spontaneously several 
hours after its withdrawal. It is alkaline in reaction. The 
occurrence of red corpuscles is most commonly encountered 
in exudates due to tuberculosis and new growths of the pleura. 

Microscopically, white and red corpuscles and detached 
endothelial cells are found. Sometimes the erythrocytes are 
found in great numbers ; it is then called a hemorrhagic exu- 
date. The amount of fluid contained in the pleura may vary 
from a small quantity to several liters. 

The pleura itself may show an extensive fibrinous exudate. 
The lung is pressed backward and upward, and may be atelec- 
tatic. Adjacent organs — the heart, spleen, stomach, and liver 
— are displaced, depending upon the amount and position of 
the fluid, whether it be upon the right or the left side. 

Symptoms. — Prodromes may occur, such as pain in the 
side, and general malaise, or the condition may begin abruptly 
with chill, fever, and severe pain from the onset. Sometimes, 
especially in children, it happens that the patient complains of 
symptoms of depression, weakness, loss of appetite, palpitation 
and breathlessness upon exertion, which is mistaken for pro- 
longed enteric fever. Upon physical examination, however, 
an extensive pleurisy is found. 

The pain does not always occur, but when present it is apt 
to be distressing, and is referred to the region of the nipple, or 
axillary region. It is aggravated by cough, by deep breath- 
ing, and by firm pressure upon the chest. Dyspnea is com- 
mon, especially with large pleural effusions. This is due 
to encroachment upon the respiratory surface of the lung. If 
the effusion develops slowly, the lung may be entirely com- 
pressed without dyspnea occurring, except, perhaps, upon 



4 H DISEASES OF THE RESPIRATORY SYSTEM. 

exertion. In large effusions the patient lies upon the affected 
side, or upon the back so as not to encroach upon the lung or 
the unaffected side. Fever may or may not be a symptom ; 
when present, it is slight, the temperature ranging from ioo° 
F. to 102° F. The pulse is slightly accelerated. 

Physical Signs. — Inspection. — Some degree of immo- 
bility of the affected side is present ; this may vary in propor- 
tion to the amount of fluid in the pleura. In massive effusions 
the affected side of the chest becomes comparatively immobile, 
and the unaffected side shows an increase in the respiratory 
excursis, taking upon itself more work. There may be some 
increase in volume of the diseased side ; this is especially true 
in large effusions with obliteration of the intercostal spaces, 
which rise up to the level of the ribs, showing a contrast in 
the inspirations between the affected and the unaffected side. 

In moderate or large right-sided effusions, the apex of the 
heart is displaced to the left and upward, found occasionally 
even in the fifth intercostal space to the left of the mammillaiy 
line. The impulse of the heart may be found to the left as 
far as the anterior axillary line. In left-sided effusion the 
impulse may be entirely absent, due to the fact that the apex 
of the heart is behind the sternum, or it may be visible in the 
third or fourth intercostal space of the right side. 

Palpation. — Palpation confirms the signs obtained upon 
inspection as to the restricted movements upon the affected 
side. It shows that the intercostal spaces bulge, and deter- 
mines the position of the cardiac impulse. In serofibrinous 
pleurisy, edema of the chest is rarely present, this being deter- 
mined by palpation. In empyema this important physical 
sign is sometimes present. Any evidence of fluctuation, such 
as occurs in ascites from effusion into the peritoneal cavity, is 
an exceedingly rare occurrence in serofibrinous pleurisy. The 
tactile or vocal fremitus over the side of the effusion is en- 
feebled or abolished ; in young children, on the contrary, it 
may be retained, as also in individuals with thin chest-walls. 
The explanation has been given that the vocal fremitus may 
be transferred through very thin walls over the unaffected 
side laterally, the vibrations being carried over to the opposite 
side. In loculated or pocketed serofibrinous effusion there 
are lines of tissue running from the peripheral pleura to the 
costal pleura, old adhesions having taken place (the lung 
being separated by the effusion). These lines of tissue may 
transfer the vibrations to the surface of the chest, producing 



PLEURISY. 415 

vocal fremitus upon the affected side. A bronchus may be 
pressed upon by a rib, and the fremitus be carried along the 
line of the rib, or in some instances the lung may be held to 
certain areas of the chest from old pleural adhesions, giving 
rise to localized fremitus. These signs are often very confus- 
ing. Mensuration is a sign of very little value. 

Percussiorf. — Over the pleural effusion the percussion note 
is flat, and extending toward the apex, becomes clear and 
tympanitic in character, known as " Skodaic resonance." 
The larger the effusion the greater the amount of flatness. 
In large pleural effusions, posteriorly a curve of an S shape 
may be made out. According to Ellis, "this curve begins 
with medium effusions relatively low down in the back, passes 
outward from the vertebral column, and soon turns upward, 
and proceeds obliquely across the back to the axillary region, 
where it reaches its highest point. Thence it advances in a 
straight line, but with a slight descent to "the sternum." As 
the effusion increases in amount, the curve rises and flattens 
so that the S-curve disappears, when the effusion reaches the 
second rib. The curve is modified by pleural adhesions and 
pathologic changes of the lung, such as consolidation and 
emphysema. The most characteristic signs of a moderate 
and large effusion are displacements of organs, particularly 
of the heart and mediastinum. This may be made out by 
palpation and percussion. 

Reference to the changes in the heart in right- and left-sided 
effusions has already been made. Depression of the diaphragm 
also occurs. It may be referred to the right side from the 
position of the lower margin of the liver, which may in ex- 
treme cases be as low as the level of the umbilicus. On the 
left a moderate degree of depression can easily be detected. 
Obliteration of " Traube's semilunar space" occurs. (See p. 
96.) Any marked depression of the diaphragm by the fluid 
will cause a perceptible diminution in the width of this zone. 
In extreme cases, not only may the splenic dullness be entirely 
obliterated, but the diaphragm may sag below the ribs as a 
prominent tumor. As a rule, these characteristic signs of de- 
pression of the diaphragm are only pronounced in very large 
pleural effusions. 

Upon auscultation, vocal resonance is absent over the flat 
area. The respiratory murmur is decreased or absent over the 
fluid. When the fluid diminishes, the voice sounds may be 
heard, but are distant and diffused. Egophony is rare. 



4l6 DISEASES OF THE RESPIRATORY SYSTEM. 



ATYPICAL FORMS. 

Resorption, or the artificial removal of a portion of the 
fluid, is indicated by a drop in the line of flatness, and by the 
diminution of intercostal tension and the rise in the diaphragm. 
Respiratory sounds and fremitus show various modifications 
tending toward a return to normal conditions. All these 
changes are, however, much less marked than might be expected, 
and especially is the return of the heart to its normal position 
slow and retarded. As the effusion disappears the friction 
sounds return, sometimes with even more intensity than at 
the beginning. Large numbers of crackling rales are heard, 
which, according to Traube, are due to the forcible entrance 
of air into the group of air-vesicles, which are opened as 
absorption progresses. 

Fibroid Thickening. — Fibroid thickening with retraction 
of the chest has already been mentioned. 

Encapsulated Effusions. — These do not produce displace- 
ments, as a rule, the other signs being the same as in ordinary 
effusions, except that they are less pronounced. Fremitus 
may be present for reasons already described. 

The mobility of pleural effusion on change of posture is 
still under discussion. Very large effusions are immovable ; 
moderate effusions reaching to the third or fourth rib in front, 
if they change their position at all, move so slightly as to be 
scarcely perceptible, and if such alterations do occur, require 
time, and can not be diagnosticated at once. 

PURULENT PLEURISY; EMPYEMA. 

Etiology. — The essential difference between a serofibrinous 
and a purulent effusion usually consists in the presence in the 
latter of certain micro-organisms in considerable quantity, and 
many pus-cells. This has been abundantly proven by the inves- 
tigation of some of the best bacteriologists. It is probable 
that most empyemas are caused by two or three particular 
forms, and when they give rise to the disease the clinical 
course may vary. It is possible that empyema may occasion- 
ally be a primary affection, but in the majority of cases the 
disease is secondary. 

The most frequent organism producing the condition is the" 
streptococcus pyogenes. The sources of the invasion into 
the pleura are from the lung ; thus pleurisy is associated with 
influenza ; ulcerative processes as from tuberculosis, abscesses, 



PLEURISY. 417 

gangrene, infarcts, bronchiectasis, and cancer ; affections of 
the skin, lymph-glands and breast, especially cancer of the 
breast ; also from the mediastinum, such as pericarditis ; 
abdominal suppurations, particularly puerperal metritis ; also 
from abscesses of the liver, stomach, or the bowels ; the acute 
affections, as diphtheria, influenza, scarlet fever, erysipelas, and 
puerperal fever. 

To produce empyema from these diseases, it is necessary 
that the micro-organism (the most frequent being the strepto- 
coccus) should invade the pleura in considerable numbers, 
and particularly that there should be some focus, close to or 
communicating with the pleura, where the conditions are favor- 
able for their multiplication. (The injection of small quantities 
of a pure culture into the pleural cavity has proved innocuous.) 

Next in importance in producing empyema is the pneumo- 
coccus of Frankel. This organism has been found in all em- 
pyemas due to croupous pneumonia. It is sometimes found 
in empyema following bronchopneumonia, as also in empyemas 
which are apparently primary. 

Tubercular empyema may arise from tubercular affection of 
the pleura, being usually chronic in character, but the effusion 
is more likely to be serofibrinous than purulent. 

Other micro-organisms are exceptionally found — the staphy- 
lococcus, the bacillus of Eberth, and occasionally the encap- 
sulated bacillus of Friedlander. 

Saprophytic bacteria are often the determining cause of the 
fetid and putrid character of the empyema. Their mode of 
access to the pleura is usually through the bronchi, through 
the gastro-intestinal tract, or an external wound. None of 
these etiologic factors may be determinable upon the post- 
mortem table. 

Pathology. — The exudate is not always purulent in its 
gross appearance, and sometimes there is no sharp line of dis- 
tinction microscopically between a serofibrinous and a purulent 
exudate, since it is entirely a question as to the number of 
pus-cells. The fluid may be thin and slightly opaque, or thick 
and viscid pus. Microscopically, leukocytes, endothelial cells, 
red corpuscles, large granular cells, fat globules, detritis, chol- 
esterin crystals, and micro-organisms are present. 

There are few changes in the pleura and surrounding tissue 
peculiar to empyema. There is extensive and deeper infiltra- 
tion of the pleura with round-cells and leukocytes, and the 
lymphatic spaces are often found engorged with pus, and the 
27 



41 8 DISEASES OF THE RESPIRATORY SYSTEM. 

blood-vessels dilated. In long-standing empyema the pleura 
shows great fibrous thickening, and the lung is compressed. 
Sooner or later necrosis of the pleura will probably follow, 
either as the result of pressure or of the local inflammatory 
process, resulting in perforation of the sac and the discharge 
of the pus in various directions. The fluid may find its way 
into the lung, either by soakage or by rupturing into a bron- 
chus, or it may form an external tumor — "empyema neces- 
sitatis." 

The entire pleural cavity may be affected, or the empyema 
may be encapsulated between the lung and chest-wall, or in 
the forms known as diaphragmatic, interlobular, or mediastinal. 

Rupture may take place either internally or externally. 

Symptoms. — The onset and symptoms of empyema are 
not typical. The condition may arise insidiously or acutely. 
In the majority of instances the affection begins insidiously. 
If it should begin acutely, there will be severe chill, with rapid 
rise in the temperature, from 102 F. to 105 ° F., severe pain 
in the side, and intense dyspnea. 

The exudate appears early, and is purulent from the begin- 
ning, or it may even be putrid. The constitution of the 
patient is affected from the onset. There is marked weakness, 
wasting, depression, dry tongue, with sordes upon the teeth, 
rapid pulse, and tendency to delirium — in fact, the so-called 
" typhoid state" is often present. A fatal issue may take 
place at the end of a week, although these cases are excep- 
tional. Often the onset is insidious, and the course may be 
absolutely afebrile. The hectic temperature curve may occur, 
but this is not characteristic. The greater number of cases 
occupy the middle line between the extreme acute and the 
very insidious onset. The symptoms may be masked at first 
by the primary disease, or the disease may develop as a typi- 
cal serofibrinous pleurisy, with moderate fever, pain, and 
dyspnea. 

As the primary affection declines, the temperature does not 
fall ; on the contrary, in perhaps ten days to two weeks it 
gradually assumes a hectic type, with chilly sensations and 
sweating. Accompanying these symptoms there is gradual 
loss of strength and flesh. The face becomes pale, dyspnea 
increases, cough is troublesome and dry, and clubbing of the 
fingers occurs in the older cases, and the urine is albuminous. 
The patient may succumb from exhaustion, or to secondary 
amyloid disease, or to some other complication. 



PLEURISY. 419 

Physical Signs. — The physical signs are those of a sero- 
fibrinous pleurisy. The character of the fluid gives no char- 
acteristic signs. Baccelli thought that he had discovered an 
important differential sign, in that the voice could be trans- 
mitted through serofibrinous exudates but not through puru- 
lent ones. This sign has been found to be unreliable, and no 
dependence must be placed upon it, as the voice-sounds are 
often equally as well transmitted through purulent as through 
serofibrinous and hemorrhagic exudates. Displacement of 
organs in empyema is more apt to be marked than in sero- 
fibrinous pleurisy. Local edema and redness of the skin is 
often present. 

Diagnosis of Empyema. — There are no positive signs 
nor symptoms by which empyema may be diagnosticated 
from serofibrinous pleurisy. 

Fever, sweating, edema, and chills are sometimes present in 
serofibrinous pleurisy as well as in empyema. Exact diagnosis 
can only be made upon aspiration. 



SPECIAL VARIETIES OF PLEURISY, 

Diaphragmatic Pleurisy. — When the inflammation is lim- 
ited to that portion of the pleura covering the diaphragm and 
the under surface of the lung, peculiar symptoms may arise. 
This, however, is not common. It may be secondary to ab- 
dominal affections or to diseases of the lung such as lobar 
pneumonia, or it may be primary, produced by the same causa- 
tive influences as other forms of pleurisy. The dry variety is 
exceptional, most cases being accompanied by small effusions, 
mostly serofibrinous, rarely purulent in character. 

The onset of the disease is abrupt, beginning with a chill 
and a pronounced febrile movement, from 103 ° F. to 104 F. 
The pain is extremely severe and referred to the hypochon- 
drium ; sometimes it is felt down the back. A pain extending 
along the course of the 'tenth rib to the sternum is supposed 
to be diagnostic. 

The face is anxious, the pulse feeble and rapid, and there is 
excessive dyspnea. The anxiety of the countenance is due to 
the extreme pain, the patient making every effort to immo- 
bilize the chest ; he may sit slightly forward with hands placed 
against the sides of the thorax, or may occupy a semirecumbent 
position, with elevated knees. The respiration is rapid, costal, 
and superficial. The abdominal wall upon the affected side is 



420 DISEASES OF THE RESPIRATORY SYSTEM. 

tense, with firmly contracted muscles, and sensitive to pressure. 
Pain may also be present at other parts of the chest, both 
anteriorly and posteriorly, and may be the result of neuritis 
of the phrenic nerve from pressure, which may persist even 
after the pleurisy has disappeared. 

Pain is increased by movement, by cough, and hiccup, 
which is occasionally a troublesome symptom. Vomiting 
frequently takes place, greatly aggravating the pain, and often 
leading to false diagnosis. In the severer forms delirium is 
frequent and may be the forerunner of a fatal coma. The 
bowels are constipated. 

Physical Signs. — The physical signs of pleurisy of this 
form are vague or may be absent altogether. Occasionally 
friction sounds may be heard at the base of the chest, but on 
account of the great pain and the slight efforts made in respira- 
tion, and their location, they are rarely heard. 

When effusion is formed the characteristic zone of flatness 
and some displacement of the liver and spleen may also be 
present. 

The disease is often mistaken for peritonitis and other grave 
abdominal affections. In pleurisy the abdomen is not dis- 
tended, the pain is superficial, and the dyspnea is a marked 
symptom. If friction is present, it aids materially in the diag- 
nosis. The prognosis of uncomplicated cases is almost always 
favorable, fatal cases being due to complications and to a puru- 
lent effusion. 

Hemorrhagic Pleurisy. — The hemorrhagic variety occurs 
in tuberculosis of the pleura, and is due to degenerative 
changes of the walls of the blood-vessels. 

Hemorrhagic effusions also result from malignant growths 
of the pleura. The diagnosis can only be made by explora- 
tory puncture. 

Chylous Pleurisy. — This form is of exceeding rarity. It 
may be due to obstruction and rupture of the thoracic duct 
and from cancerous thrombosis of the subclavian and jugular 
veins. 

Pulsating Pleurisy. — In a left-sided pleural effusion, a 
synchronous pulsation may occur with that of the heart. This 
may be noticed in several intercostal spaces upon the affected 
side. The condition is most apt to be an empyema, and is 
rare. The pulsation is situated most often anteriorly between 
the second and the sixth ribs upon the left side, and often 
forms a tumor ; there may even be two or three. 



PLEURISY. 42 1 

Pulsation posteriorly is very rare. The pulsation may be 
increased by the patient lying upon the unaffected side. 

The prognosis is grave. Pneumothorax may be present. 
This may be due to the gas production of the bacillus 
aerogenes capsulatus. 

Encapsulated Pleurisy.- — When effusions are limited by 
costopulmonary adhesions, the condition is spoken of as 
"encapsulated or encysted pleurisy." It is sometimes called 
" interlobular " if the condition occurs between the two lobes 
of the lung, or "mediastinal" if between the lung and the 
mediastinum. In the two latter instances the condition is 
almost invariably purulent. 

The diagnosis is often impossible without exploratory punc- 
ture. 

When the purulent fluid passes into the lung by an extended 
surface, by soakage, or by a fistulous tract communicating 
with a bronchus, it may find its way out through an intercostal 
space and form a tumor beneath the skin ; it is then called 
"empyema necessitatis." 

Pleurisy at the Extremes of Age. — In the aged the con- 
dition most frequently occurs as a complication of pneumonia, 
cancer, or cardiac and renal disease. Pain and fever are 
mostly absent, dyspnea is moderate, and the course of the dis- 
ease is insidious. In very young children the effusion is very 
apt to be purulent. 

Complications. — Sudden death may take place during the 
first weeks of the rapidly appearing effusion, or even later 
during convalescence. It may be due to syncope, from fatty 
degeneration of the heart, or undue pressure upon it. Throm- 
bosis of the pulmonary artery and right heart or associated 
pericarditis may cause sudden death. Fatal syncope may 
happen during aspiration. Pulmonary edema may also give 
rise to sudden death. Peritonitis occurs as a complication. 
Chronic interstitial pneumonia may follow. Gangrene may 
result from fetid pus penetrating the lung. Pneumothorax 
may be associated with pleural effusion in consequence of rup- 
ture of the lung, or the empyema may rupture into the bron- 
chus. Nephritis sometimes occurs as a complication. There 
may be clubbing of the finger-tips. Lardaceous or amyloid 
disease is a rare complication. 

Diagnosis. — In simple acute pleurisy with the presence of 
localized pain and a well-defined friction sound the diagnosis 



422 DISEASES OF THE RESPIRATORY SYSTEM. 

is easy. The condition may be mistaken for muscular rheu- 
matism, especially of the intercostal muscles. Muscular rheu- 
matism is bilateral ; the muscles are painful upon pressure ; 
movement also produces pain. 

Intercostal neuralgia sometimes gives rise to difficulty in 
diagnosis, but the locality of the pain, as also the presence 
of herpes zoster, will help to differentiate the condition. 
Gastralgia, ulceration of the stomach, and peritonitis occa- 
sionally give rise to difficulty in diagnosis, but the presence of 
the friction sounds is of service in differentiating the conditions. 

Pleural effusions may be mistaken for croupous pneumonia. 
Under the description of croupous pneumonia the differential 
table between these two diseases is given. (See p. 236.) Medi- 
astinals and tumors of the pleura are exceedingly difficult to 
differentiate from pleural effusion. An important point in 
favor of pleural effusion would be the absence of vocal fremi- 
tus, while in the other condition the fremitus may be preserved ; 
besides, in tumors there are symptoms of pressure upon the 
nerves, blood-vessels, and esophagus. These signs would be 
more in favor of tumors than pleural exudation. In all 
doubtful cases aspiration should be performed. 

Pulsating empyema may be mistaken for aneurysm, but in 
empyema there is absence of thrill and bruit over the pulsating 
mass ; besides, the pulsation in empyema can hardly be spoken 
of as expansile. Empyema necessitatis may give rise to great 
difficulty in diagnosis, but the association of involvement of 
the base of the lung of the corresponding side with displace- 
ment of organs will serve to make the proper diagnosis. 

Hydrothorax, if it be unilateral, may give rise to difficulty 
in diagnosis. The absence of friction sounds, severe pain, and 
the subfebrile rise in the temperature are of importance. A 
large pericardial effusion may be mistaken for a left-sided 
pleural effusion, but care in the physical examination, with the 
history, will help to differentiate the conditions. 

Prognosis. — Acute fibrinous pleurisy, if it be primary, is 
almost always favorable. In serofibrinous effusion, the 
etiologic factor must be taken into consideration, although 
ultimate recovery most often follows. Empyema is a very 
serious condition. In pneumococcus infection the mortality 
is very low, about 2^ or 3^, whereas in the streptococcus 
and mixed infections the mortality reaches 25^. Empyema 
of tubercular origin is a very chronic process, life being pro- 
longed, and restoration to health may even occur. 



PLEURISY. 423 

Treatment. — Dry Pleurisy. — The indication is to relieve 
pain. This maybe accomplished by the local use of dry cold, 
or sinapisms. Strapping the chest with strips of adhesive 
plaster so as to render the affected side immobile is often fol- 
lowed by marked relief. Internally, the analgesic antipyretics 
are of use, or small doses of Dover's powder or some other 
form of opium may be administered. If the pain be very 
severe, hypodermic injections of morphin may be necessary. 
If the pain continue, it may yield to small fly blisters. 

Pleurisy with Effusion. — The fluid must be removed either 
by absorption or aspiration. There are no positive signs by 
which the nature of the fluid can be definitely known ; how- 
ever, if pus is supposed to be present, aspiration should be re- 
sorted to at once. 

Counterirritants, diaphoretics, diuretics, and laxatives may 
be employed, but are of very little value. - It is recommended 
by some to exclude fluids from the diet, so as to produce ab- 
sorption. 

Should the effusion remain stationary or continue to in- 
crease, or if the fluid should reach the level of the second rib, 
or should there be evidences of grave respiratory and circula- 
tory disturbances, an exploratory puncture should be made at 
once. In instances where the effusion is complicated with peri- 
carditis or valvular lesions of the heart, immediate aspiration is 
necessary. When there is septic temperature with develop- 
ment of edema of the chest-wall, a purulent pleurisy should 
be suspected and exploratory puncture at once made. 

The operation of aspiration is not difficult. The chest is 
prepared with proper antiseptic precautions, and the point of 
selection for puncture is in the posterior axillary line in the 
seventh interspace. The patient should sit up, and rest the 
hand of the affected side upon the opposite shoulder. It is 
important to test the aspirator before the operation. The 
needle should be guarded by the fingers so that it does not 
enter the chest- wall too deeply, and then inserted into the chest 
just above the border of the rib. In this way the danger of 
wounding the intercostal artery is averted. The possibility of 
puncturing the diaphragm, or entering the liver upon the right 
side and entering the spleen upon the left side, must be remem- 
bered. It is well to withdraw the fluid slowly, and the con- 
ducting tube should be compressed from time to time for this 
purpose. 

It is not always necessary to withdraw the entire effusion, 



424 DISEASES OF THE RESPIRATORY SYSTEM. 

especially if it be very large. If urgent dyspnea, great cough, 
or pain, faintness or syncope, or the appearance of blood in 
the aspirated fluid occur, the operation should be suspended 
at once. 

After the needle has been withdrawn, the finger should be 
held over the point of puncture until cotton moistened with 
collodion or adhesive strips are applied. 

The treatment of purulent pleurisy consists in free drainage, 
with thorough antiseptic precautions. The pus is often so 
thick that it will not flow through the needle. In such cases 
a surgical operation is necessary. 

CHRONIC PLEURISY. 

The disease occurs in two forms — (a) pleurisy with effusion ; 
(b) dry pleurisy. 

{a) Pleurisy with Effusion. — This may follow the acute 
form or it may begin insidiously, the pathology being the 
same as in the acute varieties. If the fluid be absorbed or re- 
moved, there is retraction of the affected side, sometimes giving 
rise to deformity.' Subjective symptoms, with perhaps the 
exception of slight dyspnea, are mostly absent. The pulse 
may be slightly increased in frequency, and there may be 
slight evening rise of temperature. If the effusion remains for 
any time, especially in children, pus is likely to form and hec- 
tic temperature and edema of the chest-wall may develop. 
The physical signs of a pleural effusion are always present. 
The disease may last for months or years. Death is usually 
due to some chronic suppurative process or to pulmonary tu- 
berculosis. 

(b) Chronic Dry Pleurisy. — This may follow acute or 
chronic pleurisy with effusion. If the exudate be absorbed, 
the layers of the pleura, which still contain some fibrinous 
material, come together, and subsequently fibrous connective 
tissue is formed. Usually this appears most prominently at the 
base, giving rise to flattening and retraction of the chest-wall 
upon the affected side. From the great thickening of the 
pleura, impairment of resonance and some enfeeblement of the 
breath-sounds is commonly noticed. Should the condition 
have followed empyema, the retraction and flattening will be 
still greater. In these fibrous bands which stretch across the 
pleura small cysts may form. Fibrous pleurisy may follow acute 
fibrinous pleurisy, and adhesion of the layers of the pleura is 



PNEUMOTHORAX. 425 

apt to result. These adhesions are very commonly found at 
autopsies. They may be general or limited. Ordinarily, no 
change upon physical examination is noted, except when the 
adhesion is general or very thick. There is some impairment 
to expansion of the affected side, and the breath-sounds may 
be weaker, although this is by no means the rule. Friction 
sounds are sometimes heard. 

Treatment. — The effusion, if present, should be removed, 
and the general nutrition of the patient must be looked after. 
The diet should be generous. Climatotherapy and lung gym- 
nastics are of use. General tonics are especially indicated. 

PNEUMOTHORAX, 

Definition. — Air in the pleural sac. 

The presence of air alone is an exceedingly rare condition. 
In the majority of cases an effusion, either of a serous or puru- 
lent character, is also present, producing a hydropneumotho- 
rax, or a pyopneumothorax. When there is blood with air 
in the pleura cavity, the condition is known as hemopneumo- 
thorax. 

Synonyms. — Hemopneumothorax ; pyopneumothorax. 

Etiology. — This disease may arise from two sources, first, 
by perforation — (a) external perforation, (ft) internal perfora- 
tion ; second, by spontaneous development of gas within the 
sac. 

1 (a) External Perforation. — Trauma, stab wounds, gunshot 
wounds, blows, by means of the aspirator, operation upon the 
chest, and caries of the ribs, (ft) Internal Perforation. — The 
most common instances of this form of perforation are : In 
case of a tubercular cavity, this ulcerating through the visceral 
pleura ; from caseous tuberculosis without cavity formation, a 
common communication being established with a bronchus ; 
abscess of the lung and gangrene ; infected emboli, causing 
ulceration of the inner layer ; chronic bronchopneumonia ; 
emphysema ; and from an empyema, causing a perforation 
into a bronchus. Rarely, from whooping-cough, a rupture 
occurs internally. Hydatid and carcinoma have caused the 
condition. 

Sometimes the perforation is through the diaphragm, as 
from a subphrenic abscess which communicates with a perfo- 
rated gastric ulcer. 

2. In some instances pneumothorax is believed by many to 



426 DISEASES OF THE RESPIRATORY SYSTEM. 

arise from gas production due to the bacillus aerogenes cap- 
sulatus ; this, however, is doubted by. some. 

The disease is more frequent in males than females, and 
occurs most often upon the left side of the chest. 

Pathology. — It can be readily understood that from an 
external injury air may gain entrance into the pleural cavity. 
Infection frequently follows. The quantity of air that may 
find entrance into the pleural cavity varies greatly in amount. 
Displacement of adjacent organs depends upon the distention 
of the pleural sac. The air may be absorbed. 

Symptoms. — Under ordinary circumstances, with a rupture 
of the pleura sudden distressing pain is the most important 
symptom. It may occur during an attack of coughing, and 
be followed by great difficulty in breathing. The condition, 
however, may come on insidiously without pain, cough, or 
dyspnea. 

As a rule, the pulse and respiration are greatly increased 
in frequency. Cyanosis is prominent, the expression is 
anxious, the alae of the nose moving, and the auxiliary muscles 
of respiration called into activity. The extremities become 
cold ; the temperature is lowered. The patient may be bathed 
in cold perspiration ; in fact, all the symptoms of collapse are 
present. 

The dyspnea, which is perhaps the most important symp- 
tom, is often extreme. The decubitus varies ; the dyspnea 
may be so great that the patient must be propped up in bed ; 
commonly he is found lying upon the affected side. 

Physical Signs. — Inspection. — The shoulder upon the 
affected side is elevated, the intercostal spaces being partially 
or completely obliterated, the side distended, and respiratory 
movements diminished or completely absent. Respiration 
upon the unaffected side is increased. 

The impulse of the heart is displaced toward the healthy 
side, and on account of the rapid and disturbed respiratory 
excursis or the weakness of the heart's action great difficulty 
will be found in locating the impulse exactly. 

Palpation Palpation confirms inspection. The vocal 

fremitus is absent. Downward displacement of the liver, if 
the affection takes place upon the right side, will be noted. 

Percussion. — The signs upon percussion are characteristic. 
A tympanitic note is noticed high up in the chest above the 
level of the fluid. Below where the fluid accumulates, flat- 
ness is noted upon percussion. The level of tympany and 



HYDROTHORAX. 427 

flatness varies with the changed position of the patient. If the 
condition be upon the left side, Traube's semilunar space is 
found displaced. 

Auscultation. — Auscultation shows absence of breath- 
sounds upon the affected side. Occasionally rales of a distinct 
metallic quality may be found present (metallic tinkling ; gutta 
cadens). Vocal resonance is absent. The characteristic sign 
is the succussion splash, which is due to the association of air 
and fluid in the pleural cavity. The sound is elicited by 
placing the ear to the affected side and vigorously shaking the 
patient. It often has the metallic quality. The patient may 
be conscious of this sound himself. 

The coin test is elicited in this affection. By placing a coin 
upon the diseased side anteriorly, and tapping with another 
coin, the examiner listening posteriorly, a ringing, metallic, 
bell-like sound is transmitted to the ear. This does not occur 
upon the healthy side. This sign may be heard in any large 
cavity with tense, fine walls. 

Diagnosis. — The diagnosis depends upon the history, the 
pain with dyspnea, cyanosis, fall in temperature, and the asso- 
ciation of characteristic physical signs, especially the succus- 
sion sound, with displacement of organs. 

Prognosis. — The prognosis depends upon the cause. In 
simple traumatic cases the opening often becomes sealed by 
inflammatory exudation, the air being absorbed. In tuber- 
culous cases the prognosis is bad. 

Treatment. — The treatment is symptomatic and palliative. 
Opium and stimulants are particularly useful. Paracentesis 
must be considered when the effusion becomes marked. For 
the pain, strapping of the affected side is of advantage in 
some cases. It is necessary to know the nature of the fluid 
present, and if it is found to be pus surgical interference is 
necessary. 

HYDROTHORAX. 

Definition. — An accumulation of fluid, without inflamma- 
tory signs, in the pleural cavity. 

Etiology.- — This is always a secondary affection, and occurs 
commonly in chronic disease of the kidneys and heart, and 
anemic states. It may occur from the pressure of tumors, and 
is often the terminal event in many acute and chronic diseases. 

Pathology. — The disease is most often bilateral, although 
the fluid frequently is greater upon one side than the other. 



428 DISEASES OF THE RESPIRATORY SYSTEM. 

It may vary from a small amount to several liters. In dis- 
eases of the heart, one pleural cavity alone may be affected. 
If both are affected, there is often a much greater amount of 
fluid upon one side than upon the other. The fluid is clear, 
straw-colored, and of low specific gravity — below 1018. In- 
flammation or roughening of the pleura is not present. 

Symptoms. — The symptoms of the primary disease are 
always most marked. When transudation into the pleura 
takes place, dyspnea becomes a prominent symptom. It may 
be associated with cyanosis, great distress and anxiety, and 
profuse cold perspiration. Pain is absent, and cough is not 
constant. 

Physical Signs. — The physical signs are those of a pleural 
effusion without the early presence of friction sounds. If 
the disease be bilateral, displacement of organs is not a 
striking feature. 

Diagnosis. — The condition must be differentiated from 
pleural exudations. 

Differential Diagnosis. — 

Hydrothorax. Pleural Effusion. 

The disease is bilateral. The disease is unilateral. 

No pain ; cough not marked ; always Pain ; cough ; often a primary affection. 

secondary to other diseases. 

Friction sound absent. Friction sound present. 
No displacements of organs apparent. Displacement of organs common. 

No fever. Slight fever. 

Treatment. — The treatment is that of dropsy appearing in 
other parts of the body. The fluid may be removed by aspira- 
tion. Attention should be directed to the primary disease. 



HEMOTHORAX. 

Definition. — Blood in the pleural sac. 

Etiology. — Hemothorax should not be confounded with 
hemorrhagic effusion. It may result from traumatism that 
causes fracture of a rib or wounding of a lung. It may also 
result from the rupture of an aneurysm, from malignant dis- 
eases of the lung, and hemorrhagic diathesis. 

Symptoms. — The symptoms are those of hydrothorax, 
with those of blood loss. Pallor, a small and sometimes 
imperceptible pulse, great dyspnea (air hunger), and decrease 
in the quantity of urine are present. There may or may not 
be pain. 



TUMORS OF THE PLEURA. 429 

Physical Signs. — The physical signs are those of a pleural 
effusion without the friction sound. 

Prognosis. — Traumatic cases may result in cure. The 
condition, resulting from any cause, is grave. 

Treatment. — Hemothorax, if it be moderate in size, should 
not be interfered with, as subsequent absorption and clotting 
may take place. Rest and the free administration of opium 
are necessary ; avoid stimulation, for it will interfere with the 
formation of the clot. 



TUMORS OF THE PLEURA* 

Benign Tumors. — Of the benign connective-tissue tumors, 
fibromata and lipomata have been observed, the latter fre- 
quently appearing upon the costal pleura. 

Malignant Tumors. — These are rare primaryaffections. Car- 
cinomata invade the pleura by extension, this being either from 
the lungs, mediastinum, or from the mammary gland, rarely 
from more distant growths. The tumors are usually small. 
Enlargement of the cervical lymphatic glands is often present. 

Sarcomata may be primary, either springing from the endo- 
thelial layer (the endotheliomata) or from the subendothelial 
connective tissues. The sarcoma is frequently of the spindle 
cell variety. Secondary involvement of the lungs often occurs. 
G. R. Butler (" New York Medical Journal," 1895) collected 
seven cases from literature of primary sarcoma of the pleura, 
of which six affected the left side. Sarcoma may also involve 
the pleura secondarily. 

Symptoms. — There are no characteristic phenomena which 
show the development of malignant diseases of the pleura. 
Dull, persistent pain in the affected side, with great weakness 
and dyspnea, and signs of pleural effusion of a hemorrhagic 
form are often present. Some degree of cachexia is notice- 
able, and the lymph-glands, especially of the neck and axilla, 
are frequently found enlarged if the growth be carcinomatous. 
If the tumor be very large, bulging of the chest may result 
upon the affected side. In the endotheliomata there is 
retraction, with dullness or flatness upon percussion, and ab- 
sence of respiration over the affected side. The fluid present 
may obscure the signs of the malignant growth. The most 
important signs depend upon the exploratory puncture. 

The following rules have been laid down by Frankel : 
The deep-red color of the fluid, almost like that of venous 



430 DISEASES OF THE MEDIASTINUM. 

blood, the discovery upon microscopic examination of small 
particles of the growth itself, which show its organic structure, 
the presence of considerable fat, either free, as a chylous fluid, 
or inclosed in epithelial cells, are important factors. 

Prognosis. — The prognosis is grave. 

Treatment. — The treatment is palliative. 



ECHINOCOCCUS OF THE PLEURA. 

This is a very rare condition. It is most often secondary, 
but may be primary. Davaine (Traite des Entozoaires, Paris, 
i860) reported twenty-five cases of hydatid cysts of the pleura, 
only one of which he believed to be primary. In the sec- 
ondary form either the liver or the lung is the organ first 
affected. The cyst is most often single and sterile, but not 
invariably so. The disease may affect the pleura from the 
rupture of a hepatic cyst. The contents of the cyst may be 
either clear or purulent. 

Symptoms. — The onset is insidious ; occasionally there 
may be sharp or sudden pain. In any event, sooner or later 
pain becomes a prominent symptom, and is very persistent. 
As the cyst develops, dyspnea and cough appear. 

Physical Signs. — The physical signs are those of an effu- 
sion. There may be circumscribed bulging of the affected area. 
On puncture, a fluid is obtained in which hooklets may be 
discerned by the aid of the microscope. 

Prognosis. — The prognosis is serious, but not so grave as 
when found in the lung. 

Treatment. — Surgical interference is necessary, and aspira- 
tion may be performed. 



DISEASES OF THE MEDIASTINUM. 

INFLAMMATION OF THE MEDIASTINUM. 

Synonym. — Mediastinitis. 

Inflammation of the mediastinum may be simple or infective, 
acute or chronic, primary or secondary. Simple acute inflam- 
mation which terminates in resolution can not be diagnosticated. 

Etiology. — This condition may occur by extension from 
chronic pericarditis, chronic inflammation of the pleura, chronic 



ABSCESS OF THE MEDIASTINUM. 43 I 

peritonitis, and chronic inflammation of the tracheobronchial 
glands. 

Pathology. — A fibrinous exudate, later the development of 
fibrous tissue in the shape of dense bands surrounding the 
blood-vessels, trachea, and bronchi, often forms. The tissues 
undergo consolidation from contraction of the fibrous bands, 
producing pressure effects upon the veins, the aorta, the 
nerves, and may frequently be great enough to constrict the 
trachea and some of the larger bronchi. 

Symptoms. — The symptoms of this disease are often 
obscured and masked owing to the primary condition which 
precedes the disease, such as the inflammation of the peri- 
cardium, pleura, bronchi, and lung tissue. The disease may 
be diagnosticated from an increased fullness in the jugular 
veins, which steadily increases. This will be especially noted 
during inspiration, and lessened in expiration, the pulsus para- 
doxus being associated with the condition. Pain is present 
behind the sternum, which may radiate to the shoulders, back, 
neck, or chest. Dyspnea, increased upon slight exertion, is 
common. The pulse is rapid, small, easily compressed, and 
of low tension, besides having the character of the pulsus 
paradoxus. Cough with expectoration, followed later by 
cyanosis, is a common symptom. If constriction of the 
inferior vena cava occurs there will be swelling of the liver, 
ascites, and dropsy of the lower extremities. Fever may or 
may not be present. 

Physical Signs. — As a rule, there is an increase in the area 
of precordial dullness ; the apex-beat of the heart is absent, 
the sounds being faint though regular. 

Diagnosis. — This is extremely difficult, and must often be 
made by exclusion. 

Prognosis. — The prognosis is unfavorable. 

Treatment. — The treatment is palliative, symptomatic, and 
supporting. 

ABSCESS OF THE MEDIASTINUM. 

Etiology. — All the causes which have been mentioned 
under inflammation of the mediastinum may give rise to ab- 
scess, provided some pyogenic micro-organism be present. The 
streptococcus infection produces a severe spreading variety, 
the staphylococcus infection, as a rule, giving rise to the milder, 
more circumscribed forms. Trauma is a frequent cause. The 



43 2 DISEASES OF THE MEDIASTINUM. 

condition may result from actinomycosis, from erysipelas, 
pyemia, variola, scarlet fever, measles, enteric and typhus fever, 
and from other infectious diseases. The disease occurs more 
frequently in males than in females. 

Pathology. — The seat of abscess is most frequently in the 
anterior mediastinum. The pathology is that of abscess ; the 
pus finds its way between various organs, and some of these 
may be perforated. If the infection be of a slow or chronic 
nature the abscess wall may be quite thick. Various forms 
of micro-organisms have been isolated from the pus. 

Symptoms. — If the abscess be acute, the ordinary signs of 
purulent inflammation are present, such as chill, fever, sweat- 
ing, anorexia, coated tongue, vomiting, constipation which is 
followed by diarrhea, loss of flesh, anemia, great depression, 
and muscular weakness. Dry spasmodic cough, later accom- 
panied by expectoration, which is often purulent and blood- 
stained, is a symptom. The local manifestations are indefinite 
in character ; there may be a sense of fullness and constriction 
behind the sternum, which may give place to a constant dull, 
aching pain. Tenderness upon pressure is present over the 
sternum. If pressure upon the veins take place, signs of 
venous engorgement are noticed, and in pressure over the vena 
cava ascites and edema of the lower extremities result. Pres- 
sure upon the great veins gives rise to murmurs, and pressure 
upon the esophagus results in dysphagia. If there is pressure 
upon the laryngeal nerves, paralysis of the vocal cords is noted. 
The physical signs vary, depending upon the location of the 
abscess. The heart may be displaced ; the sounds are apt to 
be obscured but regular. The pulsus paradoxus is likely to 
be present. 

Prognosis. — If the abscess can be evacuated the prognosis 
is more favorable than in the deep-seated cases. Under any 
circumstance it is a very serious affection. 

Treatment. — The treatment is surgical. 



TUMORS OF THE MEDIASTINUM, 

BENIGN TUMORS. 

Lipomata, fibromata, enchondromata and osteomata rarely 
occur in the mediastinum. Dermoid and echinococcus cysts 
have been encountered in this locality. 



TUMORS OF THE MEDIASTINUM. 433 

MALIGNANT TUMORS. 

Carcinoma of the Mediastinum. — This tumor occurs more 
commonly as a primary growth than as a secondary, being 
most common in the anterior mediastinum. They occur most 
frequently between the ages of fifty and sixty. 

Sarcoma of the Mediastinum. — The most common seat 
of this tumor is also in the anterior mediastinum, it being 
more frequently primary than secondary. 

Secondary carcinoma also occurs in the mediastinum. 

Symptoms. — Tumors of fairly large size soon produce 
symptoms of pressure upon the heart or its vessels, the lung, 
the recurrent laryngeal nerve, the trachea, the bronchus, the 
large blood-vessels, such as the superior or inferior vena 
cava, the esophagus, and the sympathetic nerves. The symp- 
toms are those of dyspnea, cough, frequently of an aneurysmal 
character, difficulty in swallowing, variation in the size of the 
vessels, and other circulatory disturbances. Cyanosis and 
enlargement of the thoracic veins arise due to the attempt at 
collateral circulation. 

The physical signs are varied. If the tumor be very 
large, upon inspection there may be bulging of the sternum 
and ribs, and these bones may become eroded. If the 
growth push the heart forward, marked pulsation may be 
noted. Upon inspection, slight cyanosis and edema of the 
superficial veins may also be apparent. Upon palpation the 
vocal fremitus is found to be greatly decreased or absent. 
Upon percussion, dullness merging into flatness is present 
over the affected area. Upon auscultation indistinct or absent 
breath-sounds, with decreased or absent vocal resonance, is 
noted. If the tumor be situated anteriorly to the heart, the 
apex-beat will be faintly visible or absent, and the heart-sounds 
upon auscultation will be distant and muffled. If the tumor 
be carcinomatous in nature, enlargement of the axillary and 
cervical lymphatic glands will be noted if these have become 
invaded by the spread of the growth. 

Prognosis. — The prognosis is grave. 



2S 



PART IV. 
DISEASES OF THE DIGESTIVE TRACT. 



DISEASES OF THE MOUTH. 

CATARRHAL STOMATITIS. 

Definition. — An inflammation of the mucous membrane 
of the mouth. 

Synonyms. — Acute stomatitis ; simple stomatitis. 

Etiology. — The disease is most frequent in children, but 
may also occur in adults. The inflammation appears in the 
form of erythematous patches, so that the surface is drier than 
normal ; or a catarrhal inflammation develops, with some 
thickening and increased secretion. 

Improper food, either too hot or pungent, prolonged suck- 
ing of an ill-developed nipple, or unclean feeding bottles are 
causes. Dentition may be a cause ; and in adults, tobacco, 
stimulating food, alcohol, or an irritation from a carious tooth. 

Some drugs, such as mercury, arsenic, lead, iodin or bro- 
min, may cause the disease. It may be the result of gastro- 
intestinal disturbance, and occurs in some of the specific fevers, 
such as scarlet fever and measles, rarely in tuberculosis, car- 
cinoma, and diabetes. 

Symptoms. — The symptoms are pain, heat, discomfort, 
dryness of the mouth, and difficulty in swallowing. The child 
is fretful, saliva drivels at the mouth, and the patient may 
become wasted and feeble. There is usually slight fever, 
accompanied by vomiting and diarrhea. 

Treatment. — The treatment consists in cleanliness, careful 
feeding, and the use of mild alkaline mouth-washes. If pain 
be great, ice maybe used, or a weak solution of cocain painted 
upon the erythematous patches. A mild purge is often 
advantageous. 

434 



APHTHOUS STOMATITIS. 435 



ULCERATIVE STOMATITIS. 

Synonym. — Putrid sore mouth. 

Etiology. — The disease most frequently occurs in children 
between the ages of four and sixteen, and is usually due to 
bad sanitary surroundings, or a local irritation such as a 
decayed or carious tooth. Improper feeding may give rise 
to the affection. 

Pathology. — The pathology consists in a localized necro- 
sis of the buccal mucous membrane with surrounding inflam- 
matory infiltration. The ulceration spreads superficially. 

Symptoms. — The disease commonly appears first at the 
margin of the gum in the region of a molar tooth, oftener on 
the left than on the right side. The gum is red and swollen, 
and bleeds easily. The mucous membrane soon ulcerates, 
leaving a dirty yellow or grayish ulcer. The cheek and 
tongue upon the implicated side are also affected, and the 
ulceration may spread to the lips. 

The breath is offensive, and the lymphatic glands of the 
neck are enlarged. The tongue is thickly coated. The 
duration of the disease depends upon the extent of severity 
of the affection. 

Treatment. — Alkaline washes for the mouth, or peroxid 
of hydrogen in small doses, are effective. Chlorate of potash, 
locally, has been recommended by some authorities. 



APHTHOUS STOMATITIS. 

Synonyms. — Aphthae ; vesicular stomatitis. 

Etiology. — The affection occurs most frequently in chil- 
dren, and the usual causes which have been indicated in 
other forms of stomatitis are also prominent here. The 
disease occurs occasionally in adults, in whom it is most 
likely due to some local irritation. 

Symptoms. — Small papules, either single or in groups, occur 
in parts of the mouth, most commonly upon the inner surface 
of the lower lip. At the end of twenty-four hours the epithe- 
lial covering is lost, and a small oval, whitish patch, with 
raised edges, makes its appearance. This disappears in a 
day or two and leaves a small conical ulcer behind. Pus 
formation does not take place. The sore heals in a few days, 



43 6 DISEASES OF THE DIGESTIVE TRACT. 

new epithelium covering the ulcer. The duration of the dis- 
ease is about seven days. 

Treatment. — Constitutional difficulties must be carefully 
inquired into. The mouth should be washed before food is 
given, and weak alkaline solutions of boracic acid, five grains 
to the ounce, or a I <fo solution of permanganate of potash 
may be painted upon the spots. If there be great pain, a 
weak solution of cocain may be applied from time to time. 
A mild purge should be given at the onset. 



PARASITIC STOMATITIS* 

Definition. — The disease is a catarrhal stomatitis, associated 
with a large fungous growth, consisting of white patches of 
various sizes. The back of the tongue and the inner surface 
of the cheeks and palate show the affection most prominently. 
It is generally believed that the cause is the fungus known as 
the oidium albicans. 

Synonyms. — Thrush ; muguet. 

Etiology. — Uncleanliness, constitutional debility, and co- 
existing catarrhal stomatitis are predisposing factors. It 
occurs most frequently in children, and next commonly in 
old age. It is supposed that restricted movement of the 
tongue, which permits the lodgment and growth of the fun- 
gus, has something to do with the etiology. The acid con- 
dition of the secretions of the mouth, which seem to favor its 
growth, are probably a result, and not a cause. Unclean 
feeding bottles, spoons, etc., are sources of infection. 

Pathology. — The oidium albicans lodges upon the per- 
fectly normal mucous membrane. Occasionally a catarrhal 
condition of the mucous membrane may precede the parasitic 
growth. The parasite is simply confined to the superficial 
epithelium, and may be seen upon the tongue, cheeks, lips, 
hard palate, or the tonsils, as white spots, which are slightly 
raised, and may increase in size by extension. 
. Symptoms. — The symptoms are slight. The disease is 
noticed by an inspection of the mouth. A catarrhal stoma- 
titis is always associated. There may occasionally be diar- 
rhea and vomiting. 

Diagnosis. — Small particles of the adherent curd-like patch," 
when subject to microscopic examination, reveal the fungus. 

Prognosis. — The prognosis is favorable. 

Treatment. — The treatment consists in cleanliness. If the 



MERCURIAL STOMATITIS. 437 

child be not breast fed, a wet-nurse should be supplied. The 
fungus may be wiped off with soft linen soaked in boric acid 
solutions and solutions of carbonate of sodium, or perman- 
ganate of potassium may be of use. . In cachectic individuals 
alcohol and tonics are necessary. 



MERCURIAL STOMATITIS* 

Definition. — An inflammation of the buccal mucous mem- 
brane and salivary glands resulting from the administration 
of mercury. 

Synonym . — Pty alism . 

Etiology. — It frequently occurs in individuals who are 
especially susceptible to small doses of the drug, or it may 
arise from an excessive administration. Occupations in which 
the drug is handled may predispose. Any of the preparations 
of mercury may cause stomatitis. Small doses of calomel, 
frequently repeated, will very often produce the condition. 
When mercury, especially in the form of calomel, is adminis- 
tered, it is wise to ask the patient whether he is subject to 
ptyalism. 

Symptoms. — The early symptoms are swelling of the gums, 
accompanied by tenderness and some pain, especially marked 
on mastication. The breath in this condition is offensive. 
Accompanying these changes, the saliva increases in amount 
and may be excessive. The teeth may become loose ; ulcera- 
tion of the gums and, rarely, necrosis of the jaw may follow. 
The inflammation may spread to the pharynx and Eustachian 
tubes. When administering mercury, tenderness of the gums 
is suggestive of beginning ptyalism. A metallic taste in the 
mouth may sometimes be noticed. Diarrhea and abdominal 
pains are likely to be accompaning symptoms. 

Prognosis. — This disease is rarely of a serious nature ; 
sometimes, however, it is very distressing. 

Treatment. — The administration of mercury should be 
suspended. Mouth-washes, such as chlorate of potassium 
and listerine, are useful, and frequently the only remedies 
necessary. Doses of atropin may be beneficial. The bowels 
should be freely opened with salines. Iodid of potassium is 
sometimes useful. If pain exists, opium should be adminis- 
tered. 



43 8 DISEASES OF THE DIGESTIVE TRACT. 



GANGRENOUS STOMATITIS. 

Definition. — A disease characterized by extensive destruc- 
tion of the cheek. 

Synonyms. — Noma ; cancrum oris. 

Etiology. — This is a rare form of stomatitis, usually occur- 
ring in persons in bad health, or those subject to unsanitary 
surroundings, starvation, malaria, or other acute and chronic 
diseases. In children the disease often follows measles, and 
sometimes enteric fever. It occurs most frequently in damp 
countries. It is a disease of children between the ages of two 
and five. 

Pathology. — The first lesion is usually upon the mucous 
surface of one of the cheeks, appearing as a small bleb, fol- 
lowed by ulceration and induration of the surrounding tissues, 
which rapidly spreads over the whole cheek, the area becom- 
ing gangrenous. The area of disease is tense, may be red 
and in some instances black, and may extend to the upper 
or lower jaw, the malar bone, and sometimes the orbit. Per- 
foration of the cheek not infrequently occurs. The teeth may 
become loose and drop out. The blood-vessels show the 
greatest resistance, but hemorrhage does not take place. If 
the condition terminates favorably, a large and extensive 
cicatrix will result, causing great deformity. 

Symptoms. — One of the earliest symptoms is a foul odor 
from the mouth, with redness and swelling of the cheek. 
Pain is not usually present even when examination of the 
mouth reveals a sloughing ulcer, nor even when the bone is 
attacked. Extreme prostration, with delirium, occurs, espe- 
cially in cases terminating fatally. Bronchopneumonia is very 
apt to take place. The fever is moderate, pulse is rapid, and 
only slight swelling of the lymphatic glands occurs. The dis- 
ease usually appears on one side, it being extremely rare for 
both cheeks to be affected. Diarrhea is present, and often 
actual ulcerative colitis. Gangrene may occur in other parts 
of the body, such as the lungs, limbs, or the genital organs. 

Prognosis. — Death ensues in about Sofo of the cases. The 
prognosis depends largely upon the extent and rapidity of the. 
disease. With recovery, there is great deformity of the cheek 
and eversion of the lower eyelid. 

Treatment. — The treatment is surgical. The entire mass 
of gangrenous material should be excised, either by the knife 



CHRONIC GLOSSITIS. 439 

or the actual cautery. In anesthesia, great care must be taken 
that none of the material is swallowed or gains entrance into 
the trachea, as almost certain bronchopneumonia will result. 
Nitric acid is also used to limit the extent of the disease. The 
strength of the patient should be maintained. Liquid nourish- 
ment in a concentrated form at frequent intervals, and free 
stimulation, is necessary. Complications must be treated as 
they arise. 



DISEASES OF THE TONGUE. 

ACUTE GLOSSITIS. 

Definition. — An acute inflammation of the tongue. 

Etiology. — Exposure to cold, especially in alcoholics, is a 
frequent cause. Injury from biting the tongue, as in an epilep- 
tic paroxysm or the acute specific diseases, may give rise to 
the condition. Occasionally only one-half of the tongue may 
be affected (hemiglossitis). The disease occurs more com- 
monly in men than in women. 

Symptoms. — Pain is a most prominent symptom. The 
tongue is swollen and increased in size, the surface is dry, 
and the breath offensive. The condition may last two or 
three days. 

Treatment. — A mild saline purge, followed by antiseptic 
mouth-washes, is usually of benefit. If the pain be severe, 
painting with a weak solution of cocain will give good results. 



CHRONIC GLOSSITIS. 

Etiology. — This condition may be either superficial or deep. 
It may be due to friction from a broken tooth or any irritant. 
It is frequently the result of alcoholism and dyspepsia. 

Symptoms. — The surface of the tongue is smooth and 
glossy. Parts of the tongue are red- and raw-looking, whereas 
elsewhere it may be white. Occasionally ulceration may 
be noted. In severe cases the tongue is swollen, and marked 
by the edges of the teeth. Pain and stiffness of the organ 
may be present, aggravated by speaking and eating. 

Prognosis. — This condition may predispose to epithelioma. 

Treatment. — The diet of the patient should be regulated ; 



44° DISEASES OF THE DIGESTIVE TRACT. 

food should be plain and wholesome. Alcohol and tobacco 
must be avoided. The teeth should be carefully looked after. 
Dyspepsia and constipation must be corrected. Mild alkaline 
washes are useful. The ulcers should be painted with a weak 
solution of nitrate of silver. 



DISEASES OF THE SALIVARY GLANDS. 

HYPERSECRETION* 

Synonym. — Ptyalism. 

Etiology. — This condition results from the administration 
of certain drugs, such as mercury particularly, iodin com- 
pounds, gold, copper, jaborandi, and from the use of tobacco. 
It may accompany inflammatory conditions of the mouth, and 
sometimes the infectious diseases, such as smallpox. Dis- 
eases of the pancreas may be accompanied by hypersecretion. 
During pregnancy the condition may occur. It is sometimes 
of nervous origin. 

Treatment. — If possible, the exciting cause should be 
removed, and the condition should be treated the same as 
mercurial ptyalism. 



XEROSTOMA 

Definition. — This is a rare malady, and is associated with 
nervous disturbances, and is most frequently met with in 
women. The tongue and buccal mucous membrane become 
dry and sometimes fissured. Mastication, deglutition, and 
articulation are impaired. The condition is sometimes asso- 
ciated with diabetes. 

Synonyms. — Dry mouth ; arrest of the salivary and buc- 
cal secretion. 

Treatment. — The patient may secure relief by frequent 
use of water or oil. Occasionally pilocarpin, internally, is of 
benefit. 



INFLAMMATIONS OF THE SALIVARY GLANDS- 

Parotitis. — There are two varieties, specific parotitis, or 
mumps (already described among the infectious diseases — see 



ACUTE TONSILLITIS. 44 1 

page 261), and symptomatic parotitis ; the latter form may be 
acute or chronic, and is known as parotid bubo. 

Parotid Bubo. — Parotid bubo occurs as a complication in 
a great many of the infectious diseases, such as enteric fever, 
typhus, septic disease, tuberculosis, and pneumonia. It also 
appears in malignant diseases. It occurs in genital affections, 
such as orchitis and epididymitis, and in inflammation of the 
ovary. The parotid gland is swollen, and the affection is apt 
to be unilateral. 

Suppuration takes place in a number of the cases. The 
occurrence of parotid bubo in the course of an infectious 
disease is considered unfavorable. 

Chronic Parotitis. — This condition may follow specific 
parotitis, or inflammations of the throat. Lead, mercury, 
and chronic Bright's disease are also etiologic factors. Swell- 
ing and tenderness of the glands is present, and there may be 
hypersecretion. The disease may persist for years. 

Treatment. — Ice may be used, or ointments of iodin or mer- 
cury to favor resolution and prevent pus formation. Leeches 
are also beneficial. When pus is present speedy evacuation is 
necessary. Flaxseed poultices frequently give great relief. 



DISEASES OF THE TONSILS. 

ACUTE TONSILLITIS* 

(a) Follicular or lacunar tonsillitis ; (b) suppurative tonsillitis 
or quinsy. 

ACUTE FOLLICULAR TONSILLITIS. 

Synonym. — Acute amygdalitis. 

Etiology. — Young adults are most often affected. In chil- 
dren the chronic form, in which exacerbations take place from 
time to time, is an important factor. Exposure predisposes. 
Both sexes are equally liable. The disease ^appears most fre- 
quently in the Spring and Autumn ; one attack predisposes 
to others. It occurs epidemically. Acute rheumatic fever is 
often associated with the disease. In scarlet fever acute ton- 
sillitis is often a complication. 

Pathology. — One or both tonsils may be affected. The 
tonsils first become swollen and red ; very soon the lacunae 
are filled w T ith an exudate, which is white, and of a cheesy 



442 DISEASES OF THE DIGESTIVE TRACT. 

consistence. These points of exudation may project from 
the surface. A number of these areas are frequently found, 
which may coalesce. 

Microscopically, the changes which are found in acute in- 
flammations are present. The exudate consists largely of 
fibrin, leukocytes, epithelial cells, and various bacteria, such as 
the staphylococcus and streptococcus, the latter being the one 
most frequently associated. When the exudate is removed the 
surface of the involved tonsil does not bleed. 

Endocarditis and pericarditis have been found associated 
with it. Marked leukocytosis is present. The condition may 
terminate in the suppurative variety. 

Symptoms. — Occasionally the constitutional signs are 
slight, but in the majority of instances there is lassitude and 
malaise, and in severe cases prostration and great fatigue upon 
muscular or mental effort. Headache and pain in the bones, 
which may be violent and increase for some days, are present. 
Delirium may occur in children. The tongue is coated and 
the appetite is poor. Vomiting may take place, and constipa- 
tion is the rule. Fever is almost invariably present ; it often 
reaches 102 F., and not infrequently 104 F. or 105 ° F., 
especially in children. Chilly sensations may be present at 
the onset, and occasionally a genuine chill. The pulse is rapid 
and the respirations are increased. The fever range is not 
typical. The urine shows the changes common in fevers ; 
occasionally there is a trace of albumin, and a few hyalin, or 
granular casts, are present. The symptoms of the general 
infective process are out of proportion to the local process. 
This is especially true when the disease occurs in children. 

Tickling and burning sensations in the throat, with pain in 
swallowing, are the early symptoms. Salivation may occur. 
Muscular movement, especially of the head and neck, is pain- 
ful. The cervical glands may be enlarged. The pain in 
swallowing may radiate to the ear. Examination of the throat 
shows redness and swelling of one or both of the tonsils, with 
yellowish -white patches upon them varying in size from a pin- 
head to a split pea. These may be stripped off, leaving an 
intact mucous membrane beneath. The breath may be foul. 
At the height of the disease, murmurs may be heard over the 
base of the heart. It must be borne in mind that true endo- 
carditis is sometimes met with in the course of this affection, 
and that the murmurs present are not necessarily hemic in 
origin. 



ACUTE TONSILLITIS. 443 

Differential Diagnosis. — 

Follicular Tonsillitis. Diphtheria. 

Exudate limited to the tonsils. The exudate upon the pharynx, uvula, 

and tonsils. 
The exudate occurs in the follicles. The exudate is extensive. 

The exudate strips off with ease, but The exudate is stripped off with diffi- 
no bleeding surface left beneath. culty, leaving bleeding surface and 

probably reforming. 
Streptococci frequently found in the Klebs-Loffler bacillus present, 
exudate. 

Course and Prognosis. — The acute symptoms usually dis- 
appear in from two to three days. The prognosis is favorable. 

Treatment. — The disease is self-limited and can not be 
aborted. The patient should be put to bed and a laxative 
administered. The coal-tar products, especially phenacetin, 
in small doses, guardedly given, promptly relieve the pain. 
Quinin in large doses is useless. Local treatment, as a rule, 
is not of much benefit. Ice bandages and small particles of 
ice in the mouth are useful. Liquid nourishment should be 
given, preferably in the form of cold drinks. If pain and 
sleeplessness are present, opium, especially Dover's powder, 
may be administered. 

SUPPURATIVE TONSILLITIS. 

Synonyms. — Quinsy ; abscess of the tonsil. 

Etiology. — The disease occurs most frequently in males 
between the ages of twenty and forty, being more common in 
the spring and late autumn. Certain families show a marked 
liability to the disease ; one attack predisposing to others. 
Many writers regard it as in some way associated with acute 
rheumatic fever. Persons with chronic hypertrophied ton- 
sils are more apt to suffer from quinsy than from the follicular 
form. The attack is preceded usually by exposure to cold, or 
one of the eruptive diseases, or by a preceding attack of fol- 
licular tonsillitis. 

Pathology. — It may be unilateral or bilateral. The tonsils 
become swollen, red, and edematous, and sometimes the sur- 
rounding structures are also inflamed. Abscess formation 
frequently results, and rupture may occur externally — this 
being the more common — or internally. The carotid artery 
has been known to rupture, due to an extension by the 
inflammation. 

Symptoms. — The disease most often begins with a severe 
chill, followed by high temperature (104 F. or 105 ° F.), 



444 DISEASES OF THE DIGESTIVE TRACT. 

with severe pains in the back and limbs, headache, and 
constipation. The pulse is rapid, and the local distress, 
especially when both tonsils are involved, is enormous. Sleep 
and relief of pain is often impossible without the use of opiates. 
The pain in the throat is severe, the mouth being opened only 
with great difficulty. It is not confined to the tonsil, but may 
shoot to the ear, the floor of the mouth, or to the angle of the 
jaw. It is deep seated, gnawing, and often neuralgic in char- 
acter. Salivation is present, the secretions of the mouth being 
fetid. The voice is thick, muffled, and nasal, and if the 
Eustachian tube be pressed upon, deafness and noises in the 
ears result. If the exudation be absorbed the symptoms 
speedily disappear. More commonly, fluxation may be made 
out in the tonsil in from two to four days, and rupture takes 
place some time between the fifth and tenth day. If this 
does not occur, in extreme cases suffocation may take place. 

An abscess which points toward the soft palate often 
breaks sooner than one which shows a tendency to extend 
into the posterior wall of the pharynx. The amount of pus 
discharged is usually small. 

Diagnosis. — The diagnosis may be impossible for a day or 

two. After a few days fluxation may be noticed in the tonsil. 

, Prognosis. — The prognosis may be considered as favorable 

to life. Complications do not occur if early incision into the 

tonsil is made. 

Treatment. — Salines and cathartics are useful. Early 
incision of the affected tonsil should be made. The salicylates 
in some cases showing marked rheumatic tendency sometimes 
relieve pain. Local applications of ice or poultices are a relief 
to some patients. Cocain is of little benefit. For the severe 
pain, opium in some form is necessary. When fluxation can 
be elicited, free incision should be practiced. 

CHRONIC TONSILLITIS* 

Synonyms. — Mouth breathing ; chronic nasopharyngeal 
obstruction. 

Etiology. — The disease appears most frequently in children 
and young adults. It may follow some of the eruptive fevers, 
especially diphtheria. It is sometimes congenital. 

Pathology. — It may be unilateral or bilateral, and consists 
of hyperplasia of the lymphoid structure of the tonsil. The 
interstitial stroma in some instances is increased, and the 



ACUTE PHARYNGITIS. 445 

organs then become firmer in consistency. Adenoid vegeta- 
tions are sometimes present. Catarrh of the nasal pharynx 
usually accompanies this condition. 

As a result of long-continued mouth breathing deformities 
of the chest arise. These deformities may be one of three 
varieties : 

(a) Pigeon-shaped breast, or chicken-breast, in which form 
the prominence of the sternum and lateral depressions known 
as " Harrison's grooves " occur (see p. 53). 

(6) The barrel-shaped, or inspiratory chest (see p. 51). 

(<r) The funnel-shaped chest (Trichterbrust ; see p. 53). 

Symptoms. — Breathing at night is laborious. The child 
has attacks of night -terrors. Snoring is common ; the throat 
becomes dry, and cough occurs. Stuttering and habit chorea 
develop in some instances. The voice is altered, often becom- 
ing husky and having a decided nasal twang. Swallowing is 
difficult. The patient often has a vague, listless expression. 
Children with enlarged tonsils are liable to "colds " and at- 
tacks of acute tonsillitis. They are also often subject to 
attacks of croup. Upon inspection of the mouth the enlarged 
tonsil can readily be seen. 

Treatment. — The treatment consists in removal of the 
hypertrophied tonsil. This may be done either by the tonsil- 
lotome or, preferably, by the cautery. Local applications of 
iodin and chromic acid are useful in shrinking the tonsil. 



DISEASES OF THE PHARYNX. 

ACUTE PHARYNGITIS. 

Definition. — Acute inflammation of the pharynx. This 
occurs in association with inflammation of the soft palate and 
the tonsils. 

Synonym. — Sore throat. 

Etiology. — Exposure to cold, bad air, etc., may be etiologic 
factors. There is frequently a connection between the diseases 
of the stomach and diseases of the pharynx. Smoking, use of 
alcohol, and highly seasoned food may be predisposing causes. 
Nasal obstruction is an important cause. Occasionally the 
disease is epidemic. It may be of rheumatic origin. 

Symptoms. — Constitutional symptoms are rarely marked. 
There may be a subfebrile temperature. There is a scratchy 



446 DISEASES OF THE DIGESTIVE TRACT. 

feeling in the throat, with a frequent desire to swallow. The 
tickling in the throat may give rise to a dry cough. Upon 
examination the pharynx is at first dry and reddened ; later a 
grayish-white secretion may be seen. The attack lasts from 
two to six days. 

Treatment. — Inhalations of steam are grateful. Hot 
gargles are of decided use, hot milk being perhaps best for 
this purpose. A mild purge may be given at the onset. 



CHRONIC PHARYNGITIS. 

Synonyms. — Chronic follicular pharyngitis ; chronic gran- 
ular pharyngitis ; and, when the dry variety occurs, or the 
atrophic form, it is known as pharyngitis sicca. 

Etiology. — The disease begins in childhood, but its mani- 
festations are often masked by hypertrophied tonsils. When 
the condition persists in adult life it causes much annoyance. 
The excessive use of the voice is frequently a causative factor. 
Pharyngitis sicca occurs from previous or associated atrophy 
of the turbinated bones. 

Symptoms. — Dull pain in the throat upon speaking or 
swallowing, hoarseness, dry cough, and tickling in the throat 
are common symptoms. Examination will show bright red 
masses on the pharynx, the whole pharynx rarely being of the 
same color. The uvula is not necessarily elongated. 

Treatment. — The hypertrophied follicles may be removed 
by galvanocautery. In the dry form the nasal pharynx should 
be frequently cleaned, sprays of menthol and benzoated gly- 
cerin being useful. 

RETROPHARYNGEAL ABSCESS. 

This is most frequent in children. It may result from caries 
of the cervical vertebra, and is sometimes a sequel of the in- 
fectious diseases, particularly diphtheria and scarlet fever. 

Symptoms. — -The patient becomes restless, and swallowing 
is difficult. There are changes in the voice. Pain is a con- 
stant symptom. On inspection a projecting mass may be 
noted upon the posterior wall of the pharynx. Fluctuation may 
be noticed upon palpation. 



Treatment. — The treatment is surgical. 



ACUTE ES0PHAGIT1S. 447 



DISEASES OF THE ESOPHAGUS. 



ACUTE ESOPHAGITIS. 

Definition. — Acute inflammation of the esophagus. 

Etiology. — This is a rare affection. It may result from 
exposure to cold. Hot and very cold drinks, alcohol, to- 
bacco, and irritating substances, such as mustard, may cause 
it. Drugs, especially if irritating and remaining for some 
time in the esophagus, may cause the condition, and may 
lead to spasmodic contraction. The disease may arise from 
extension due to gastric or pharyngeal affections. It occurs 
in some of the infectious diseases, such as diphtheria and 
variola. The commonest cause is from the swallowing of 
corrosive substances ; other causes are injuries from foreign 
bodies, spinal caries, abscess of the mediastinum, and suppu- 
rating tracheal and bronchial nodes. 

Pathology. — The amount of inflammation depends upon 
the character of the irritant. It may be of the simple catar- 
rhal variety, or sometimes of the ulcerative form, often leading 
to extensive formation of cicatricial tissue and contraction. It 
is rarely phlegmonous or pseudomembranous, which usually 
results from extension. From the lodgment of a foreign 
body acute suppurative inflammation may follow, and this 
may terminate in gangrene. Hemorrhage may take place 
from acute inflammation. 

Symptoms. — The principal symptom is difficulty in deglu- 
tition, which may last for days or weeks. Attempts at swal- 
lowing are accompanied by burning, which may continue for 
several hours after partaking of food. 

Regurgitation of food may occur before the food reaches 
the stomach. From the small amount of food taken the nu- 
trition suffers, and rapid wasting may be a symptom. 

In the purulent form, fever with slight rigors, and even with 
pronounced chills, may be present. 

Blood, pus, mucus, and shreds of necrotic tissue may be 
brought up if the process be suppurative or gangrenous. 
Thirst is often pronounced. It is often difficult to differentiate 
between the mild and severe forms of the disease. 

The esophagoscope may reveal the extent of the inflamma- 
tory process. 

Prognosis. — In the simple catarrhal form the prognosis is 



44-8 DISEASES OF THE DIGESTIVE TRACT. 

favorable. In the suppurative varieties death may result from 
perforation, gangrene, or subsequent stricture. 

Treatment. — Fluid diet should be given until the acute 
symptoms subside. If liquids can not be taken, nutritive ene- 
mata may be substituted. Cracked ice is often grateful to the 
patient, and soda bicarbonate, placed upon the tongue and 
slowly swallowed, often gives relief. The salts of bismuth in 
emulsion, or the dry bismuth salts, placed upon the tongue 
and swallowed without water, may lessen the pain. Hydro- 
chlorate of cocain in half-grain doses may be beneficial. It 
may become necessary to administer opium to relieve the suf- 
fering of the patient. 

CHRONIC ESOPHAGITIS. 

Etiology. — This is produced by repeated attacks of the 
acute or the subacute form. All causes which give rise to 
the acute variety give rise to the chronic. 

Passive congestion of the esophagus, such as may occur 
from pulmonary or cardiac diseases, may cause the affec- 
tion, and it frequently accompanies tubercular and syphilitic 
lesions. 

Pathology. — Chronic esophagitis may be either of the 
chronic catarrhal variety or of the atrophic form, in which 
there is new-formed connective tissue present, showing a 
tendency to contract, causing stricture. 

Symptoms. — The disease may exist without giving rise to 
any symptoms. Occasionally there is deep substernal sore- 
ness, especially if the passage of food gives rise to difficulty 
and pain upon swallowing. 

Diagnosis. — The diagnosis can not be made with accuracy, 
but must be made by exclusion. The esophagoscope may 
show the true nature of the affection. 

Prognosis. — The prognosis depends upon the cause. 

Treatment. — The treatment is the same as in the acute 
variety. 

SPASM OF THE ESOPHAGUS* 

Synonym. — Esophagismus. 

Etiology. — This condition occurs frequently in hysteric 
patients and hypochondriacs. It takes place in affections such 
as chorea, epilepsy, and particularly hydrophobia. It may 
accompany the lodgment of foreign bodies in the esophagus. 



STRICTURE OF THE ESOPHAGUS. 449 

The so-called idiopathic form occurs in females of nervous 
temperament. Occasionally it is found in elderly males. 

Symptoms. — The patient complains of difficulty in deglu- 
tition, and in the most marked cases liquids may be regurgi- 
tated. The attack usually comes on suddenly, with or with- 
out substernal pain. The passage of the bougie may be 
temporarily arrested at the point of the spasm, which soon 
relaxes, with or without slight effort. The condition is rarely 
fatal. 

Diagnosis. — The diagnosis, as a rule, is not difficult. The 
occurrence of the disease in young persons of neurotic tem- 
perament, and the ease with which the esophageal bougie 
passes, are diagnostic. In elderly persons malignant stricture 
must be excluded. 

Treatment. — The passage of the bougie often gives prompt 
relief. Tonics are necessary, and the general health should 
be looked after. 



STRICTURE OF THE ESOPHAGUS. 

Etiology. — This may be due to congenital narrowing ; 
healed ulcers, resulting from corrosive poison and syphilis ; the 
growth of tumors in the walls of the esophagus ; external pres- 
sure by aneurysms, enlarged lymphatic glands, tumors, and 
rarely from pericardial effusion. 

Pathology. — The stricture may occur in any part of the 
esophagus, and under rare circumstances involves nearly the 
whole tube. In the greater number of cases it is found either 
high up near the pharynx or low down near the cardiac ex- 
tremity of the stomach. The stenosis may be either extreme 
or slight. 

Symptoms. — When the stricture appears low down, the 
esophagus is commonly dilated and the walls hypertrophied. 
When it is high, food is generally rejected at once, whereas if 
the stricture be low down a considerable quantity may collect 
before regurgitation. The rejected material is alkaline in 
reaction ; this and auscultation showing that it has not reached 
the stomach. 

The constitutional symptoms depend greatly upon the 
cause, whether it be a malignant growth or a stricture result- 
ing from a cicatrix. 

Emaciation and marked anemia soon become pronounced 
if the stricture be complete. 
29 



45° DISEASES OF THE DIGESTIVE TRACT. 

Prognosis. — Prognosis depends upon the nature of the 
stricture, whether it be simple or malignant. In simple 
stricture resulting from cicatrix frequent dilatation renders the 
prognosis favorable. 

Treatment. — Gradual dilatation by the esophageal bougie 
may be practised ; however, great care should be exercised in 
its passage, especially if malignant disease with ulceration be 
suspected. In this event it is safer to use a soft, flexible tube. 
Rectal alimentation is frequently necessary to sustain life. 
Surgical interference is often of great value. Gastrotomy may 
be performed. 

TUMORS OF THE ESOPHAGUS. 

These are usually malignant, carcinoma being the most fre- 
quent. It may be primary or secondary. It is more preva- 
lent in males than in females. Its most common seat is in the 
upper third of the esophagus, but there is much difference of 
opinion as regards the most frequent location. 

The most common form of carcinoma found is the squa- 
mous cell variety ; however, scirrhous and encephaloid cancers 
have been noted. Suppuration frequently results. Colloid 
degeneration of these tumors has been observed. Secondary 
deposits are most frequently found in the surrounding lymph- 
glands, sometimes in the lungs, liver, kidneys, and other 
organs. 

The growth may involve the entire circumference of the 
esophagus, or may be only partial. Perforation and hemor- 
rhage sometimes occurs as a result of ulceration. 

Sarcoma of the esophagus is rare. 

Of the benign epithelial tumors, papillomata are the most 
frequent. Of the benign connective -tissue tumors, fibromata 
and myomata have been found. If the tumor causes stricture, 
dilatation of the upper part of the esophagus frequently fol- 
lows. 

Symptoms of Carcinoma. — Difficulty in swallowing, first 
of solids and later of liquids, coming on gradually, is sug- 
gestive of this condition. There is pain upon swallowing, 
made worse by forcible attempts at deglutition. Occasionally 
painful deglutition may come on suddenly. The pain may be 
felt between the shoulders. If the growth appears in the 
lower part of the esophagus the pain in swallowing is not so 
marked. 



DILATATION OF THE ESOPHAGUS. 45 I 

Regurgitation of food is frequent, the vomited matter often 
containing blood-streaked mucus, sometimes even sloughs of 
the growth. The dysphagia is progressive. Hunger is a 
pressing symptom, the breath is offensive, and hiccup, 
associated with thirst and dryness of the mouth, is present. 
Rapid emaciation, with marked loss of weight and great 
debility, are pronounced features. 

The cachexia of malignant disease shows itself in well- 
marked cases. The leukocytosis of malignant diseases is 
sometimes absent, for in starvation the leukocytes tend to 
decrease. 

Symptoms of Sarcoma. — Sarcoma of the esophagus gen- 
erally occurs in younger individuals. The condition is ex- 
tremely rare as a primary growth. ,The symptoms are those of 
rapid emaciation and those just enumerated. 

Benign Tumors. — The benign tumors simply cause symp- 
toms of obstruction, but may produce death. 

Course and Progress of Malignant Disease. — The course 
of the disease is rapid, death being due either to exhaustion, 
starvation, sepsis, pulmonary, or other complications. 

Prognosis. — The prognosis is grave. 

Treatment. — The treatment is usually surgical. Gas- 
trotomy may prolong life. Opium should be given to relieve 
pain. Rectal alimentation may be employed. 

DILATATION OF THE ESOPHAGUS, 

This may be a simple cylindric dilatation as the result of 
obstruction, or the formation of a diverticulum. The latter is 
usually produced by traction from without, or may also be 
caused by internal pressure, and arises most often at the junc- 
tion of the esophagus and the pharynx. It is more often 
found in males than females, and is most prevalent after the 
fortieth year of life. 

RUPTURE OF THE ESOPHAGUS* 

This may result from severe vomiting, especially if the wall 
of the esophagus has been previously diseased. 



452 DISEASES OF THE DIGESTIVE TRACT. 



DISEASES OF THE STOMACH. 
GASTRITIS* 

(a) Simple acute gastritis ; (6) severe acute and toxic gas- 
tritis ; (c) phlegmonous gastritis ; (d) chronic gastritis. 

SIMPLE ACUTE GASTRITIS. 

Synonyms. — Acute catarrh of the stomach ; acute catar- 
rhal gastritis. 

Etiology. — Simple gastritis is a common affection. The 
disease may be primary or secondary. In the majority of 
instances the condition is due to irritants, either thermic or 
chemic, that come in contact with the mucous membrane of 
the stomach, producing an acute inflammation. Food either 
too hot or too cold, spices, drugs, and poisons, may have this 
influence upon the mucous membrane. Large quantities of 
food remaining in the stomach for some time may give rise to 
an acute atony, and produce gastritis. Decomposed food, 
especially such as is taken in the warm seasons, may cause 
acute gastritis, producing a form of ptomain poisoning. 

It may be due to a fungous growth in the stomach, which 
is spoken of by some writers as mycotic gastritis. Parasites, 
such as the larvae of some flies, and ascarides sometimes may 
be etiologic factors. Alcohol is probably the most common 
cause. The disease which gives rise to catarrhal gastritis is 
particularly acute parenchymatous nephritis, as was first 
pointed out by Fenwick. The disease also occurs in the 
course of scarlet fever, erysipelas, measles, and variola. 

Pathology. — The surface of the stomach is usually covered 
with a thick, ropy, mucous or mucopurulent exudate. It may 
be streaked with blood. The epithelial lining shows granular 
degeneration and desquamation, with some infiltration of 
leukocytes in the submucous layer ; less commonly there is 
hemorrhage. 

Symptoms. — The disease may show all grades of severity. 
As a rule, fever is not present. The appetite is lost. There 
is a sense of pressure and weight in the epigastric region, 
with nausea and eructations, these symptoms being followed 
by vomiting of the foul, sour, scarcely digested remains 
of food. More or less mucus is mixed with the vomited 
material, which is acid in reaction, and sometimes contains bile. 



GASTRITIS. 453 

The tongue is covered with a thick, grayish coating. It is 
swollen, and the margin shows the indentation of the teeth. 
The patient usually complains of a sour, disagreeable taste in 
the mouth, and shows great aversion to food. Thirst is 
increased. The epigastric region appears swollen, and is 
tympanitic and painful. Headache, with some vertigo and 
lassitude, is usually present. The urine is decreased in 
amount, high-colored, and contains uric acid, and often in- 
dican. 

The pulse is rapid, small, and compressible. In the mild 
cases recovery soon follows. In the severer forms vomiting 
becomes frequent, the patient continuing to suffer from the 
symptoms enumerated. The condition may go on and pro- 
duce a similar disturbance in the bowel. Constipation is at 
first the rule. Should the duodenum become affected, jaun- 
dice may make its appearance. 

Occasionally, herpes labialis appears in those cases in 
which fever is present. It is of a marked remittent character ; 
however, the normal temperature is soon reached and main- 
tained. 

Prognosis. — The prognosis is favorable ; relapses, how- 
ever, are common. 

Treatment. — Rest is important, many cases recovering 
without the use of drugs. Calomel and castor oil, especially 
in children, should be administered. The diet should be re- 
stricted for a time. In severe cases it may be necessary to 
promote vomiting by the use of an emetic or the administra- 
tion of warm water. In some cases lavage is indicated. Small 
pellets of ice should be given to relieve thirst. 

SEVERE ACUTE AND TOXIC GASTRITIS. 

Etiology. — Many authors prefer the term toxic gastritis, 
and probably most of the severe forms are due to toxic influ- 
ences. The poisons which directly influence the mucous mem- 
brane of the stomach, especially in concentrated solutions, 
are the mineral acids, carbolic acid, the caustic alkalies, alco- 
hol, phosphorus, arsenic, corrosive sublimate, potassium chlo- 
rate, potassium cyanid, and others. These chemicals produce 
a severe form of gastritis. They give rise to symptoms in 
varying grades of severity, acting either upon the empty or 
partially filled organ. 

Pathology. — The inflammation excited by the causes men- 
tioned in the etiology is of an acute variety. Large areas of 



454 DISEASES OF THE DIGESTIVE TRACT. 

necrosis, and sometimes large ulcers, are formed when the 
necrotic tissue separates. Hemorrhage frequently results. 
Microscopically, leukocytic infiltration, areas of hemorrhages, 
dilatation of the blood-vessels, and necrotic tissue will be 
noted in the submucous, and sometimes muscular and peri- 
toneal coats. 

With healing, the extensive cicatrix causes great deformity, 
which may produce pyloric or cardiac stricture. Leukocy- 
tosis may be found. 

Symptoms. — Promptly upon the ingestion of toxic sub- 
stances the symptoms of a general intoxication develop. If 
the poison be taken in fluid form, the mouth, pharynx, and 
esophagus are likely to be first affected. Pain upon deglu- 
tition, felt in the pharynx and esophagus, under the sternum 
and epigastrium, quickly appears. It is severe in character, 
often described as burning. This is soon followed by vomit- 
ing, which is frequently repeated, accompanied by much 
nausea. The vomited matter contains particles of food, mixed 
with mucus and blood, and sometimes shreds of the mucous 
membrane of the stomach. Upon examination of the epigas- 
tric region decided tympany may be noticed, although this is 
not by any means constant ; occasionally retraction in this 
region may be found. 

Palpation of the epigastric region causes pain. The face is 
pallid, covered with cold sweat, and the expression shows 
evidence of suffering. The pulse rate is increased in fre- 
quency, the pulse being small and compressible. The ex- 
tremities are cold and cyanotic. The respiration is increased, 
thoracic, and superficial. In aggravated cases peritonitis and 
perforation may occur. Death is due to collapse in many 
persons. These acute and serious symptoms only develop 
from corrosive acids or alkalies, when death may occur in 
from an hour to a day or two. 

When recovery ensues, stenosis of the esophagus or pylorus 
may form, or the disease may merge into the chronic variety. 

Diagnosis. — The history ot the case is important. The 
evidence of inflammation upon the lips, tongue, or pharynx 
may show the nature of the poison swallowed. The acute 
onset and the symptoms just described render the diagnosis 
easy. 

Prognosis. — The prognosis depends upon the poison and 
the amount swallowed. Toxic gastritis is always a very 
serious affection. 



GASTRITIS. 455 

Treatment. — The indication is to get rid of the poison 
promptly, and to administer the proper antidote as soon as 
possible. Should the toxic agent not give rise to vomiting, 
the stomach must be washed out at once. Emetics which act 
promptly should be employed. Diluent drinks, frequently re- 
peated, are of value. Purges act too slowly, hence their use 
is not indicated. Heart tonics must be used if signs of failing 
circulation occur. Opium in some form is often necessary to 
relieve pain. 

PHLEGMONOUS GASTRITIS, 

Etiology. — The disease is more prevalent in men than in 
women, in early adult or middle life. Alcohol is an important 
etiologic factor, probably being the predisposing cause in one- 
fifth of all cases. The disease may immediately follow the 
partaking of a heavy meal, after excessive eating, or periods 
of fasting. Injury may give rise to the condition. Among 
the primary factors the so-called idiopathic form of blood- 
poisoning, or septic infection, is the principal cause. Occa- 
sionally the condition may be secondary following injury or 
operation, such as from ulcers or cancers. 

Pathology. — The phlegmonous inflammation may be local- 
ized o*r diffused. When localized, the abscess may be quite 
large, and rupture into the cavity of the stomach. 

On examination of the stomach-wall it will be found greatly 
thickened. Ulceration may be present, involving the submu- 
cous coat. Microscopically, a dense leukocytic infiltration 
will be noted, as well as necrotic areas. Micro-organisms 
are found in great numbers, most often the streptococci. The 
muscular and serous coats may be involved. Pyemic manifes- 
tations may be noted in other organs. 

Symptoms. — The symptoms are not always character- 
istic. The onset is sudden. The epigastric pain and vom- 
iting are most constant. The disease has been divided into 
two periods, the symptoms before and after peritonitis has 
set in. Pain is present in the majority of cases, which is 
often violent, cutting, or burning in character, and commonly 
appears upon the first day of the disease. It increases in 
severity, and rarely subsides for any length of time. Often 
it is localized to the region of the epigastrium, but becomes 
general with the onset of peritonitis. The increased signs 
of resistance upon palpation are noticed in the epigastrium 
at an early period, these becoming most marked when peri- 



456 DISEASES OF THE DIGESTIVE TRACT. 

tonitis occurs, the abdomen then becoming prominent, swol- 
len, and tympanitic. Vomiting is an almost constant symp- 
tom. It may be preceded by anorexia and nausea, and often 
occurs upon the first day, sometimes being kept up continu- 
ously, and only ceasing with death. The vomited matter is 
at first watery, containing food and mucus, but it soon be- 
comes tinged with bile, being yellow or greenish in color. 

According to Reigel, pus has never been found in the 
vomited material. A slight degree of jaundice appears. Fever 
is usually present, the temperature ranging from ioo° F. to 
104 F. The pulse is full, strong, and but slightly accelerated ; 
later it becomes rapid, feebler, and irregular. There may be 
diarrhea or constipation ; occasionally they alternate. The 
tongue is dry and covered with a white coat. Thirst and 
anorexia are prominent. Wandering delirium, followed by 
coma and collapse; and the " typhoid state " sets in shortly 
before death. 

Diagnosis. — The diagnosis depends upon the sudden onset, 
the localized pain, the bilious vomiting, the severity of the 
symptoms, and the accompanying peritonitis. The diagnosis 
must often be made by exclusion. 

Prognosis. — The prognosis is hopeless. The course of 
the disease is rapid, and the duration brief. 

Treatment. — The treatment is purely symptomatic. Rec- 
tal alimentation must sometimes be resorted to. 

CHRONIC GASTRITIS. 

Synonyms. — Chronic gastric catarrh ; chronic dyspepsia. 

Etiology. — The conditions giving rise to acute gastritis 
cause the chronic form. Free indulgence in acid substances 
may give rise to the condition. Alcohol in a concentrated 
form may act as an irritant. Overeating, especially of rich 
foods that produce fermentation, is a causative factor ; also 
rapid eating, and ingestion of great quantities of food with ice- 
water at meals, as is so habitual with Americans, are impor- 
tant causes. 

Carcinomata of the stomach and gastric ulcers frequently are 
accompanied by gastric catarrh. Bright' s disease and per- 
nicious anemia are frequent causes. Obstruction of the return 
flow of blood from the stomach, such as results in atrophic 
cirrhosis of the liver, valvular disease of the heart, and pulmo- 
nary diseases, may bring about the condition. 

Pathology.— The stomach is usually dilated, although 



GASTRITIS. 457 

sometimes it is decreased in size. The mucous surface is 
covered with a thick layer of mucus ; sometimes the membrane 
is discolored. The veins may be distended and tortuous. 

On microscopic examination the epithelium and glandular 
structures are found almost constantly atrophied. Connective 
tissue is increased, sometimes causing increased thickness of 
the stomach-wall ; this is especially true when the stomach is 
decreased in size. 

Symptoms. — The disease is chronic in its nature, and per- 
sists for a variable period. The early symptoms are a sensa- 
tion of fullness after eating, sometimes accompanied by vom- 
iting, eructation of sour gases, and palpitation of the heart. 
The tongue is coated with a grayish-white fur, and is moist. 
There may be pain after the ingestion of foods ; most fre- 
quently, however, there is pain at all times upon pressure in 
the epigastric region, which will be very- tender. Loss of 
weight and marked secondary anemia usually accompany the 
condition. In some instances the appetite becomes variable, 
and there is craving for certain kinds of food. The bowels are 
usually constipated, in many cases obstinately. Cough, some- 
times spoken of as stomach cough, accompanies the disease. 
Nervous manifestations, such as headache, depression of 
spirits, melancholia, and irritability, not infrequently appear as 
manifestations. 

Gastric Contents. — Examination of the gastric contents 
after the 'administration of a test-meal reveals the following: 
Large quantities of mucus are present. Hydrochloric acid is 
most commonly diminished, and rarely completely absent, but 
sometimes the hydrochloric acid is found normal. Lactic acid 
may occasionally be present, especially when the material for 
examination contains large quantities of mucus. 

Diagnosis. — The diagnosis of chronic gastritis is often diffi- 
cult, and depends upon the gradual onset, distress after eating, 
and examination of the stomach -contents. The diagnosis 
between malignant diseases of the stomach and gastritis is 
often extremely difficult. 

Treatment. — The treatment consists in the careful regula- 
tion of diet. Food should be masticated thoroughly and 
taken in small amounts. Fats, alcohol, and sugar should be 
avoided as much as possible. In severe cases a liquid diet, 
milk preferably, should be instituted. Medicinal treatment 
consists in the administration of hydrochloric acid well diluted, 
before meals. Pepsin, pancreatin, and bitter tonics have been 



45 8 DISEASES OF THE DIGESTIVE TRACT. 

found of use. Constipation should be treated by such laxa- 
tives as cascara sagrada, and occasionally a mild calomel purge 
or salines are beneficial. Systematic lavage is of great use in 
the majority of cases ; electricity and massage of the abdomen 
may be found of service. 



DYSPEPSIA. 

This is a term used to designate imperfect, difficult, or pain- 
ful digestion. 

Etiology. — The condition is due to many causes. Irregu- 
lar meals, improper food, swallowing food without thorough 
mastication, cold and hot drinks, and the abuse of alcoholic 
liquors are all causative factors. 

Nervous influences play an important part in the causation, 
such as mental overwork immediately after meals, bad news, 
worry, anxiety, and dissipation. 

Want of exercise is important. The influences of microbes, 
especially those in the mouth, may give rise to forms of dys- 
pepsia. 

Finally, the disease is symptomatic in many affections and 
constitutional diseases. It occurs in adhesions of the intes- 
tines, in cases of floating kidney, and is often one of the 
first symptoms of incipient phthisis. 

Dyspepsia is very apt to lead to chronic gastritis, and often 
is associated with neurosis of the stomach. 

Symptoms. — The symptoms are extremely variable. Com- 
monly there is coated tongue, anorexia, and even disgust for 
food. Nausea and vomiting may be important symptoms. 
There may be a feeling of depression in the epigastrium, pain, 
fullness, eructation, pyrosis, acidity, constipation, and diarrhea. 

Any one of these symptoms may assume special promi- 
nence and the others be masked. Fever is rarely present. 
The urine may contain excess of solids, but otherwise is 
usually normal. 

In forms of dyspepsia characterized by great flatulence, ac- 
celerated and disordered action of the heart from pressure of the 
overdistended colon upon the precordial spaces may take place. 

The patients are often sleepy after meals, and unfit for 
mental or bodily exertion. In the so-called "nervous dys- 
pepsia " there may be headache, vertigo, anesthesia, hyper- 
esthesia, paresthesia, and occasionally even delusions and hal- 
lucinations may take place. 



ULCER OF THE STOMACH. 459 

Diagnosis. — It is always necessary to exclude organic 
diseases of the stomach and other constitutional affections, 
especially if these symptoms should occur in the aged. The 
occurrence of these symptoms, with the history of want of 
exercise, hasty eating, improper food, etc., will usually give 
the clue to the true nature of the illness. It must not be 
forgotten that this_disease also occurs in childhood. 

Prognosis. — In simple, uncomplicated cases the prognosis 
is favorable. 

Treatment. — It is important to instruct the patient to 
thoroughly masticate the food, and a restricted diet should be 
instituted. Large quantities of fluids had better not be 
allowed at meals. Oils, starches, and sugars should as far as 
possible be excluded from the daily dietary. Systematic exer- 
cise, in which fatigue should be avoided, should be insisted 
upon. 

Abdominal massage is often of decided value, especially 
if constipation be a symptom. The drugs which have been 
found to be especially useful are the mineral acids, the alka- 
lies, bitter tonics, and digestive ferments, such as pepsin and 
pancreatin. The constipation may be relieved by suitable 
drugs. 



ULCER OF THE STOMACH, 

Definition. — A disease of the stomach, characterized by 
local pain, vomiting, and hematemesis. 

Synonyms. — Perforating ulcer ; round ulcer ; simple ulcer ; 
peptic ulcer. 

Etiology. — The disease is common, especially in the female 
sex, occurring about twice as often in females as in males, most 
often between the ages of twenty and forty. The disease is 
frequent among the poorer classes. It is often associated 
with other ailments, especially the various forms of anemia, 
tuberculosis, syphilis, scurvy, septicemia, and pyemia. 

Etiologically, there is an undoubted connection between 
chlorosis and gastric ulcer. Trauma plays some part in the 
production of gastric ulcer, but this connection must be put 
down as rare. By most authorities it is claimed that heredity 
may have something to do with the production of the disease. 

Pathology. — The most common situation of the ulcer is 
near the pyloric end of the stomach, on the posterior wall, 
near the lesser curvature. 



460 DISEASES OF THE DIGESTIVE TRACT. 

The ulcers may be either single or multiple. They are 
usually circular in outline, varying in diameter from a few 
millimeters to six or eight centimeters, or may be oval ; it is 
frequently funnel-shaped, but sometimes it is punched out, the 
edges being quite irregular and overhanging. The depth varies 
from a slight erosion to a deep ulcer with indurated, greatly 
thickened walls. Embolism and thrombosis may give rise 
to ulceration. In some instances the ulcer perforates, giv- 
ing rise to either local or general peritonitis. When the in- 
flammation is local, adhesions may spring up from surrounding 
structures and a subphrenic abscess be formed. Such ab- 
scesses are occasionally quite large, and have been known to 
rupture into the pleura, pericardial sac, liver, spleen, pancreas, 
or they may produce general peritonitis. If the ulcer be situ- 
ated on the anterior wall, perforation will be followed by gen- 
eral peritonitis. 

Copious hemorrhage results from the necrotic process, in- 
volving the vessels. The glandular elements of the stomach 
are more active, so that hydrochloric acid is increased. 

When healing of the ulcer occurs, a stellate scar is often 
produced, which is not infrequently found during postmortem 
examination. From the contraction of the scar, if it be situ- 
ated in the neighborhood of the pylorus, not infrequently 
stenosis of this orifice is produced ; if near the center of the 
organ, the Jwur-glass stomacli may result. If the ulcer be 
situated near the cardiac orifice, the healing process may 
cause a stricture there. If the ulcer is of long standing, car- 
cinoma has been known to follow. 

Symptoms. — In some cases the symptoms are absolutely 
characteristic, whereas in other cases it is almost impossible to 
diagnosticate the condition. The most constant of the 
symptoms is the pain, which occurs paroxysmally, and is 
localized. It commonly appears during digestion, and is 
aggravated by the taking of food. The most common situa- 
tion of the pain is at the ensiform cartilage (pit of the stom- 
ach). The pain is sometimes described as circumscribed, 
gnawing, burning, and aching, and occasionally radiates to 
the back. The slightest pressure even of the clothing is some- 
times unbearable. Occasionally the pain is entirely absent. . 

The quality of food is of great influence in the production 
of pain. Very hot and cold fluids do not generally produce 
pain, but solids are almost certain to give rise to a more or 
less well-defined paroxysm. Tenderness is common in the 



ULCER OF THE STOMACH. 46 1 

entire epigastric region. A spot painful upon pressure may 
be found posteriorly in the dorsal region. The next symptom 
in frequency is vomiting. This generally takes place in from 
one to three hours after the ingestion of food. It may occa- 
sionally be due to the great pain. There are associated nausea, 
pyrosis, and eructation of gas of varying grades of severity. 
The vomited material consists of the stomach-contents, being 
markedly acid in reaction, due to the increase of free hydro- 
chloric acid, often containing blood-streaked mucus. The 
blood is often bright red in color, exceedingly rarely of the 
" coffee-ground " variety. Microscopically, epithelial cells, 
red blood-corpuscles, and masses of granulation tissue are 
often observed. 

Hemorrhage may be so copious as to lead to fatal collapse. 
Generally dyspnea is present. The tongue is clean, moist, 
and red, and is rarely coated. Thirst is increased and the 
appetite is variable. The patients have desire for food, but on 
account of the pain refrain from taking it. Occasionally there 
is increased appetite and even bulimia. It is rare for the ap- 
petite to be entirely wanting. There are pyrosis and car- 
dialgia. Constipation is often extreme ; rarely there is diar- 
rhea. 

The patient is almost certain sooner or later to show a high 
grade of anemia of the chlorotic type, but sometimes the 
erythrocytes are greatly reduced in numbers. After profuse 
hemorrhage numbers of nucleated red blood-cells may be ob- 
served with the accompanying leukocytosis. Digestive leuko- 
cytosis is said to be increased in gastric ulcer. Dysmenorrhea 
and amenorrhea are common. Fever is not a symptom of 
gastric ulcer. Loss of weight is not marked, excepting where 
stenosis of the pylorus or cardia should occur. 

Complications. — Perforation, with general or local peri- 
tonitis, carcinoma, and occasionally pernicious anemia are 
important complications. Subphrenic abscess, as described in 
the pathology, results from perforation, circumscribed peri- 
tonitis following. The abscess is situated beneath the dia- 
phragm, more frequently to the right than to the left of the 
median line. If situated on the left side, increased area of 
dullness will be noted in the left hypochondriac region, and 
the heart and lungs may be displaced upward. 

Great tenderness upon pressure is noticed in the region cor- 
responding to the abscess. The symptoms are not always 
diagnostic. The temperature is usually of the septic type. 



462 DISEASES OF THE DIGESTIVE TRACT. 

Hiccup, due to irritation of the diaphragm, may be present, 
and there may be edema of the lower parts of the thorax 
posteriorly. 

Subphrenic abscess may be due to other causes besides per- 
forating gastric ulcer. Ulcer of the duodenum, perforation of 
the appendix, and abscess of the liver may also give rise to 
it ; however, the majority of cases are due to ulcer of the 
stomach. 

It is especially important to diagnosticate an abscess which 
occupies the part beneath the diaphragm. The sign that the 
lung dilates upon inspiration, that pure vesicular breathing is 
present, are important points in this connection. The lower 
parts of the thorax show bulging of the interspaces ; edema 
in these parts may be present. The heart is but slightly or 
not at all displaced, but the liver is usually found low down 
in the abdomen, at or below the umbilicus. 

Subphrenic abscesses may be so small and occupy so 
limited an extent that the physical signs may be entirely 
absent. 

Clinical Varieties of Ulcer of the Stomach. — The Hem- 
orrhagic Variety. — This may have either an acute or a chronic 
course. In either case, the variety is characterized by copious 
and severe hematemesis. This may be so excessive that the 
patient dies as a result of the hemorrhage. Occasionally the 
disease runs an acute course, and after severe blood loss rapid 
recovery follows. In this form the stools are very apt to be 
tarry and show the presence of blood. 

The Acute Perforating Variety. — The symptoms of the 
ulcer may be attended with slight or no dyspeptic symptoms. 
Suddenly, and without apparent cause, perforation develops, 
which in the majority of cases rapidly leads to death. In 
this variety the ulcer is almost always situated upon the ante- 
rior wall of the stomach. 

The Chronic Dyspeptic Variety. — In this variety the dys- 
peptic symptoms are most marked. The symptoms are those 
of a chronic gastric catarrh. There is pain, particularly after 
taking food, tenderness upon pressure in the epigastric region, 
and occasionally vomiting. There is marked hyperacidity, 
due to excess of free hydrochloric acid. This latter fact is 
important from a diagonistic standpoint. 

The Gastralgic or Nervous Variety, — In this variety pain 
and tenderness assume prominence, the other symptoms being 
more or less masked. 



ULCER OF THE STOMACH. 463 

The Variety Characterized by Vomiting. — This was first 
described by Lebert. It is characterized by almost continuous 
painful vomiting, the patient retaining little or nothing upon 
the stomach. Rapid wasting assumes alarming proportions in 
this variety. 

The Cachectic Variety. — In this form the patient shows a 
high grade of cachexia. He is pale, and loss of flesh is 
marked, and the symptoms resemble carcinoma. These 
symptoms occur particularly in the later stages of long-stand- 
ing ulcer appearing in elderly people. Hypersecretion is 
present, and cicatrices from old healed ulcers are apt to be 
noticed at the autopsy. 

Course of the Disease. — The course of the disease is most 
often chronic, the condition having been designated chronic 
ulcer of the stomach. Even after apparent cure, relapses may 
take place from time to time, with a return of the initial symp- 
toms. Sometimes in the aggravated form, as has already been 
indicated, some cases may run a more or less acute course. 

Lebert has estimated the average duration of the disease as 
from three to five years. It may last longer than this, some 
cases having been observed that have run a course of from, 
twenty to thirty years. The cases of long duration are most 
often complicated, particularly by stenosis of the cardia and 
pylorus. 

Diagnosis. — In the diagnosis of ulcer it is not only impor- 
tant to diagnosticate the actual existence of the affection, but 
its position, and if possible the question of whether it be single 
or multiple, or whether it be complicated by some other affec- 
tion. 

The general diagnosis depends upon pain in the epigastrium, 
which is localized and paroxysmal, being increased by taking 
food, and the excess of free hydrochloric acid in the gastric 
contents. In connection with these symptoms, eructation, 
cardialgia, and vomiting make the diagnosis all the more cer- 
tain. 

Leube advises in all cases of doubt to make a therapeutic 
diagnosis — that is to say, all patients that are suspected of 
having gastric ulcer should be put upon treatment. 

The differential diagnosis between ulcer and cancer of the 
stomach will be given in the description of cancer. The dif- 
ferential diagnosis between ulcer of the stomach and ulcer of 
the duodenum can only be made with the greatest difficulty. 
In ulcer of the duodenum the pain is felt over toward the 



464 DISEASES OF THE DIGESTIVE TRACT. 

right parasternal line. The blood is not apt to be vomited, 
but passed in the stools. The pain occurs later after taking 
food than in ulcer of the stomach. The localized area of 
pain in the region of the ensiform cartilage is absent. Hyper- 
acidity of the gastric contents may be absent. 

Ulcer of the duodenum may arise after extensive cutaneous 
burns. It occurs more frequently in the male than in the 
female sex, and especially in alcoholics. Vomiting may also 
be absent in ulcer of the duodenum. Occasionally, jaundice 
is present. 

Ulcer must be differentiated from attacks of gastralgia, espe- 
cially taking place in neurasthenic and nervous subjects. The 
points that favor gastralgia are the variability of the appetite, 
longing for certain kinds of food, the irregularity with which 
the pain occurs after the taking of food, pain even being dimin- 
ished by pressure in the epigastric region, and the absence of 
hematemesis. Hyperesthesia is sometimes present in this 
affection, but never assumes the grade that appears in ulcer. 

It is exceedingly difficult to make out the exact position of 
the ulcer. Signs that point to the ulcer having its position in 
the anterior wall are excessive tenderness and the presence 
of tumor. Pain in the back and great vomiting point to the 
posterior wall. Great gastrectasis points to the pylorus or 
duodenum as the seat of the ulcer. 

Prognosis. — The sooner treatment is instituted the more 
favorable the prognosis. Relapses, however, are common 
even in cases that are most carefully and cautiously treated. 
The mortality of ulcer of the stomach has been estimated as 
from S fc to 10 fo. As has already been indicated, the posi- 
tion of the ulcer is most important from a prognostic stand- 
point, the cases in which the ulcer is situated upon the ante- 
rior wall being the most dangerous. 

Treatment. — Rest in bed is most important even in the 
mildest cases. Food should be withheld from the stomach for 
some time, rectal alimentation being resorted to. If great 
thirst is a prominent feature, small pellets of ice placed upon 
the tongue from time to time maybe useful. Milk is the best 
food ; it may be given either hot or cold, according to the 
individual taste of the patient. External applications over the 
epigastrium, such as hot poultices frequently renewed, are of 
value. Occasionally, turpentine stupes relieve pain. A diet 
consisting of neutral ice cream (vanilla) is grateful to many 
patients. 



MALIGNANT TUMORS OF THE STOMACH. 465 

Many drugs have been given to effect a cure, among the 
most useful being bismuth in large doses, twenty to thirty 
grains, three to four times daily, salol, oxid of silver, carbon- 
ate of soda, carbolic acid, and cocain. 

If the pain becomes excessive, opium and sometimes can- 
nabis indica may be resorted to. 

The treatment should be continued for some time after the 
symptoms have subsided, great caution being enjoined in refer- 
ence to subsequent diet. The constipation should be relieved 
by means of Carlsbad salts or other salines. Lavage must be 
used with great caution, and especially in cases characterized 
by marked tendency to hemorrhage. 

MALIGNANT TUMORS OF THE STOMACH. 

CARCINOMA. 

Synonyms. — Carcinoma ventriculi ; malignant disease of 
the stomach. 

Etiology. — The stomach is a very common seat of cancer. 
By some authorities it is claimed that no other organ shows" 
primary cancer as frequently as the stomach (Riegel). 

It is more prevalent in the male sex than in the female. 
The majority of cases occur between the fortieth and seven- 
tieth years of life. Prior to this time cancer of the stomach is 
quite rare, although cases of congenital cancer have been 
reported, one instance being that of a child five weeks old. It 
is very rare in the tropics, being most common in the temper- 
ate and colder climates. Heredity seems to play some part 
in the production of the disease, although this is questioned by 
some authorities. Cancer sometimes follows ulcer of the 
stomach, and this is not so rare as has been supposed. There 
is no evidence that chronic indigestion leads to cancer of the 
stomach. 

Pathology. — The most frequent seat of carcinoma of the 
stomach is at the pylorus. According to Lebert, it is found 
in 51 % of the cases : the lesser curvature is involved in i6f , 
the cardiac orifice in 9%, the greater curvature in 4^, and 
diffuse infiltration in 6 <f of the cases. 

A number of varieties have been found, such as the en- 
cephaloid carcinoma, scirrhus carcinoma, squamous cell car- 
cinoma, adenocarcinoma, and colloid carcinoma. 

The gross appearance of carcinoma of the stomach varies 
30 



466 DISEASES OF THE DIGESTIVE TRACT. 

greatly. The involvement may be limited or quite extensive. 
The surface, as a rule, shows marked ulceration, and sometimes 
" cauliflower projection." The color of the growth is usually 
grayish red : the consistency is either soft or hard, depending 
upon the variety present. In the scirrhous form a hard, indu- 
rated mass is observed, which if situated at the pyloric orifice 
may cause complete obstruction. 

In the encephaloid variety the tumor is soft. In the colloid 
variety it is gelatinous. 

Microscopically, epithelial cells will be found proliferating 
in the lymph-spaces, involving, as a rule, all the coats of the 
stomach. In some instances, true adenomatous growths will be 
found in some parts of the tumor, being called adenocarci- 
noma. As in all carcinomata, blood-vessels will not be found 
in the collections of epithelial cells. In the scirrhous variety 
a great amount of fibrous connective tissue is present between 
the groups of cells. 

The superficial area frequently shows necrotic changes and 
leukocytic infiltration. The blood-vessels are usually eroded, 
from which hemorrhage results. If stenosis of the pyloric 
orifice is present, dilatation of the stomach will be noticed. In 
some instances this is very marked, the lower border of the 
stomach often reaching to the level of the umbilicus or below 
it, and the pylorus being found in the right iliac fossa. If 
stenosis be present at the cardiac orifice, the gastric walls 
reveal atrophy, and the organ is decreased in size. 

Adhesions of the stomach may form with the liver, the 
anterior abdominal wall, the colon, and the pancreas. 

Metastasis to the lymphatic glands is most common ; the 
liver is next in order of frequency. The omentum, intestines, 
pancreas, lung, spleen, pleura, and other organs have been 
found involved. If the blood-vessels be implicated, the 
tumor may spread by the blood stream, and general carcinosis 
result. 

Perforation of the stomach from carcinoma may occur, but 
this is rare. The involvement of the gastric tubules, with 
their destruction, produces a decrease or absence of hydro- 
chloric acid. Anemia is present in all cases. The erythro- 
cytes, as a rule, are slightly decreased ; in some instances the 
number may be increased, due to blood concentration, and in" 
a few cases a marked decrease may be present. Hemoglobin 
shows a marked decrease, so that the chlorotic type of anemia 
is usually present. Leukocytosis (called malignant leukocy- 



MALIGNANT TUMORS OF THE STOMACH. 467 

tosis) generally appears, but when starvation results, for ex- 
ample, if a tumor be present at the cardiac orifice, the number 
of leukocytes may be normal. 

Symptoms. ^The disease begins insidiously, with extremely 
variable symptoms, or the symptoms may be so pronounced 
that the diagnosis of carcinoma of the stomach can not be 
doubted. On the other hand, as Osier (" Philadelphia Medi- 
cal Journal," February, 1900) has recently pointed out, the 
symptoms may be so latent that carcinoma of the stomach 
is found only upon the postmortem table. 

The onset in the majority of instances is insidious, affecting 
individuals between the ages of forty and sixty years. The 
patient gives the history of having been free from general 
dyspeptic symptoms until recently, when anorexia, a sensa- 
tion of fullness in the epigastrium, with eructation or other 
signs of a mild gastritis, appeared. In- rare instances the 
disease may begin suddenly, sometimes following influenza ; 
these cases are, however, exceptional. 

At the beginning of the disease dyspeptic symptoms arc of 
a mild grade, but yield very stubbornly or not at all to treat- 
ment. As a rule, the appetite is lost, and there is often actual 
disgust for food. Pain of some degree of severity is always 
present, although it is not so severe nor so marked as in ulcer. 
The pain is not localized, but is diffused, often radiating ante- 
riorly and posteriorly. 

Vomiting is a frequent and important symptom. In the 
greater number of cases it is late in its onset, and is especially 
marked in those cases in which the seat of the lesion is at the 
pylorus. The vomiting is quite characteristic, occurring every 
day or every other day. The vomited material is usually 
copious in amount, containing undigested particles of food, 
having a sour, offensive smell, even containing particles of 
blood, and large quantities of mucus. In some cases of 
carcinoma vomiting may be absent altogether. The quantity 
of the vomited material varies greatly ; it may be from one- 
half to two or more liters. When large quantities are vom- 
ited gastrectasis is present. Occasionally there is bile in the 
vomited material. 

Microscopic examination of the vomit reveals many bacte- 
ria. The Oppler-Boas bacillus is most constantly found, and 
it is supposed to be responsible for the formation of lactic 
acid. Red blood-cells and leukocytes are usually found, 
as well as epithelial cells. In some instances irregular 



468 • DISEASES OF THE DIGESTIVE TRACT. 

groups of epithelial cells are present, these being parts of the 
cancer. 

The vomited matter may consist almost entirely of " coffee- 
ground " material, which is altered blood. 

After the administration of a test-meal, the material for 
examination in almost all instances shows the absence of free 
hydrochloric acid and the presence of lactic acid. 

The bowels are constipated. This may be due to the fact 
that very little food reaches the intestines. Emaciation of 
some grade develops in all cases, which is often extreme, the 
patient rapidly losing many pounds in weight. 

The cancerous cachexia usually develops early. The most 
important phenomena are those which relate to the local ex- 
amination of the affected parts. The tongue is thickly coated, 
being covered by a copious, tough layer of mucus. The 
lymphatics of the neck are sometimes enlarged. The temper- 
ature is almost always subnormal unless inflammatory compli- 
cations occur. 

Late in the disease edema of the extremities is noticed ; 
rarely does ascites develop, which may be due to pressure 
upon the portal vein. Coma is not uncommon, v. Jaksch 
being the first to call attention to this symptom complex in 
malignant diseases. The urine shows no constant character- 
istic changes. Albumin and casts are present in a number of 
cases, and indican is frequently found. Glycosuria, peptonu- 
ria, and acetonuria are sometimes present. 

Physical Signs. — Inspection of the abdomen gives impor- 
tant results. In advanced cases the belly wall is relaxed, and 
the tumor may be noticed in the affected area. These signs 
are intensified by inflation of the stomach by means of Seidlitz 
powder or other methods. Gastroptosis and gastrectasis may 
be best noticed by this method. 

Palpation is of great importance. This produces tender- 
ness, even upon slight pressure. To determine the exact posi- 
tion of the tumor, it is advisable to fill the stomach so that 
all the relations of the parts may be made out. In rare 
instances the tumor can not be felt. Tumors of the pylorus 
are movable toward the right and downward, rarely upward. 
Tumors of the posterior wall and of the lesser curvature can 
rarely be palpated. In advanced cases enlargement of the in- 
guinal glands is noted, and nodular masses may be made 
out throughout the abdomen, indicating glandular involve- 
ment. 



MALIGNANT DISEASES OF THE STOMACH. 469 

Complications. — A rare complication is tetany. It is espe- 
cially observed in cases characterized by marked gastrectasis. 
Metastasis occurs in many organs. 

Course of the Disease. — The duration of the disease varies. 
It may ordinarily be estimated as from one to two years, the 
hard carcinomata lasting longer than the soft varieties. Occa- 
sionally the duration of the disease is longer than two years. 

Diagnosis. — The direct diagnosis depends upon the appear- 
ance of dyspeptic symptoms in a person between the fortieth 
and sixtieth years of life, with pain of varying grades of intens- 
ity, and tenderness upon pressure in the epigastric region, 
often increased by the taking of food, the vomited matter con- 
taining " coffee-ground " material, examination of the gastric 
contents by means of a test-meal, the absence of free HC1, the 
appearance of the tumor, the great and rapid emaciation, the 
cachexia, and the subnormal temperature. 

Differential Diagnosis. — 

Gastric Cancer. Gastric Ulcer. 

Most prevalent in the male sex, occur- More prevalent in the female sex, in 

ring between the fortieth and sixtieth adolescence. 

years. 

Marked emaciation, with cachexia. Emaciation not present or slight ; ane- 
mia marked. 

Vomiting of " coffee-ground ' ' material ; Vomiting of bright-red blood common ; 

rarely bright-red blood; vomiting rarely ''coffee-ground" material; 

late after taking food, often in large vomiting almost immediately after 

amounts. eating. 

Absence of free hydrochloric acid ; Excess of free hydrochloric acid. 

presence of lactic acid ; pepsin di- 
minished. 

Presence of palpable tumor. No tumor. 

Prognosis unfavorable. Prognosis as to life is good. 

Perforation and peritonitis rare. Perforation and peritonitis more fre- 
quent. 

Prognosis. — The prognosis is grave. 

Treatment.— The most important point in the treatment 
relates to the early diagnosis of the condition, with the hope 
of operative interference. Medicinal methods are only 
palliative. They consist in the alleviation of the dyspeptic 
symptoms and the pain. To accomplish these ends, sys- 
tematic lavage and the use of opium are the most satisfactory 
agents. Strength may be maintained by rectal alimentation. 

SARCOMA OF THE STOMACH, 

Sarcomata may be primary or secondary. They are most 
common in young individuals between the ages of twenty and 
thirty-five years. The symptomatology is not characteristic. 



470 DISEASES OF THE DIGESTIVE TRACT. 



NONMALIGNANT TUMORS OF THE STOMACH. 

Fibroma, fibromyoma, adenoma, papilloma, and lipoma of 
the stomach have been observed. 



FOREIGN BODIES IN THE STOMACH. 

Foreign bodies in the stomach are sometimes mistaken for 
tumors. The insane and hysteric women have been known to 
swallow hair, which may aggregate into a large mass. Many 
other bodies may be swallowed, such as false teeth, etc. 
Operative interference is necessary in some instances. 

HEMORRHAGE FROM THE STOMACH. 

Synonym. — Hematemesis or gastrorrhagia. 

Etiology. — Hemorrhage from the stomach may arise from 
a number of conditions, such as cancer, ulcer, from local 
destruction such as occurs from acids or alkalies, active or 
passive congestion, especially from obstruction to the portal 
circulation, in the course of atrophic cirrhosis of the liver, and 
from mechanical injuries, such as wounds inflicted either in- 
ternally or externally. It may also arise from constitutional 
disturbances, such as hemophilia, melena, pernicious anemia, 
and purpura hemorrhagica, also yellow fever, smallpox, 
and acute yellow atrophy of the liver. It has been known 
to arise in hysteria. The rupture of aneurysms may produce 
hemorrhage, and in some instances blood gains entrance to the 
stomach from other parts, most frequently being swallowed. 

Symptoms. — If the blood loss be copious, there is faintness 
followed by syncope, coldness of the surface and extremities, 
sweating, and subnormal temperature, sighing respiration, 
small, weak pulse, occasionally accompanied by convulsive 
movement, and later blood may show itself in the stools, 
indicated by their tarry character. 

Treatment. — The treatment is the same as in hemorrhage 
taking place in other internal conditions. 



DEFORMITIES OF THE STOMACH. 47 1 

DILATATION OF THE STOMACH, DISPLACE- 
MENTS OF THE STOMACH, AND 
OTHER DEFORMITIES. 

Dilatation of the stomach is called gastrectasis. The syn- 
onym for dropping of the stomach is gastroptosis. The 
stomach varies as to size in different individuals, the normal 
adult stomach holding about 1700 c.c. 

GASTRECTASIS. 

Etiology. — The dilatation may be acute or chronic. It 
may be due to obstruction of the pyloric end, such as con- 
genital stenosis, the cicatrices resulting from gastric ulcer, and 
from tumors, the most common being carcinomata. Thicken- 
ing of the pylorus occasionally arises without apparent cause. 
The pyloric orifice may be narrowed from external pressure, 
tumors of various kinds, and adhesions. Foreign bodies, such, 
as hair balls, coins, etc., may obstruct the pyloric orifice and 
give rise to the condition. The obstruction may take place 
in the duodenum from the causes just enumerated. 

Motor insufficiency of the stomach may give rise to dilata- 
tion. This results from overeating and the ingestion of large 
quantities of fluids, and is frequently met with in beer-drinkers. 
It appears in chlorosis, tuberculosis, diabetes, and other 
chronic or exhausting diseases. The stomach-wall may be 
diseased and give rise to gastrectasis, which is common in 
chronic catarrhal gastritis. 

Chronic dilatation is principally a disease of adults in middle 
life. If it occurs in old persons it should give rise to suspicion 
of malignant disease. 

Acute dilatation is frequently a disease of young persons, 
of children, and particularly of infants, as, for instance, the 
"potbelly" appearing in rickety children. The dilatation 
may be only temporary, and may take place without injury to 
the organ. 

Pathology. — The degree of dilatation varies, in some in- 
stances being enormous, the lower border of the stomach 
reaching far below the level of the umbilicus. The capacity 
of the stomach is sometimes greatly increased ; in the cases 
mentioned by Blumenthal the vomited material weighed six- 
teen pounds. The stomach-walls are usually thicker than 
normal. Catarrhal inflammation, as a rule, is present. The 



47 2 DISEASES OF THE DIGESTIVE TRACT. 

stomach-wall may reveal other pathologic changes, depending 
upon the causation. 

Symptoms. — The symptoms are, general feebleness, ane- 
mia, emaciation, thirst, scanty urine, sallow and hollow-eyed 
face, feeble flabby coated tongue, pyrosis, chilliness, cyanosis, 
subnormal temperature, and nervous manifestations. Pain 
and vomiting are always present and most definitely indicate 
the nature of the affection. The pain is particularly felt after 
taking food. If associated with lesions of the cardia or 
pylorus, it is almost constant. It is often immediately relieved 
by emptying the stomach, as from vomiting or by siphonage. 
Thirst and hunger are common symptoms. The urine is 
scanty and often deficient in chlorids. It is frequently alka- 
line, containing triple phosphates, and albumin being often 
present. Constipation of an obstinate kind is conspicuous, 
occasionally alternating with diarrhea. Emaciation is often 
marked. The nervous symptoms consist in depression of 
spirits, melancholy, sleeplessness, tinnitus, vertigo, and visual 
disturbances. Occasionally syncope, convulsions, and even 
tetany may occur, the patient dying in coma. 

Physical Signs. — Inspection. — Emaciation is marked. 
Often the distended outline of the diseased organ can be 
seen. Peristaltic movements of the stomach may also be 
noted. Occasionally inspection is negative. The outline 
of the stomach may be demonstrated by means of the X-rays, 
as described by C. L. Leonard, of Philadelphia, a bismuth 
mixture being introduced into the stomach so that the shadow 
is produced. 

Palpation. — Occasionally upon palpation with slight pres- 
sure over the epigastrium a splash is produced. This is due 
to the enormously dilated stomach being partially filled with 
fluid. If a tumor is present it may be detected, particularly 
at the pylorus. 

Percussion and auscultation are of very little value. Upon 
auscultation, sometimes, by shaking the patient, the succussion 
splash may be heard. 

The stomach-tube must frequently be introduced beyond 
the normal limit in order to siphon out the contents. The 
amount of liquid which the stomach contains will determine 
the extent of dilatation. The presence of free hydrochloric 
acid varies, depending upon the cause. 

Prognosis. — The prognosis depends upon the underlying 
condition. The disease is obstinate, and most often incurable. 



DEFORMITIES OF THE STOMACH. 473 

Treatment. — Lavage, or siphonage as it is sometimes called, 
is of benefit in the majority of cases, care being taken not to 
overload the stomach and not to allow liquids to remain. Ab- 
dominal massage is of use in many instances, but should be 
practised by an experienced person. Electricity has also been 
recommended. Drugs have been found unsatisfactory. Laxa- 
tives should be administered from time to time. Bitter tonics 
have been found of use in aiding digestion. The diet should 
consist largely of solids. In some instances operative inter- 
ference in relieving stenosis is of decided value. 

GASTROPTOSIS. 

Definition. — Downward displacement of the stomach. 

Etiology. — This may result from the causes just enumer- 
ated in gastrectasis, and sometimes accompanies the displace- 
ment of other organs. Glenard described the downward dis- 
placement of the viscera known as visceroptosis. It some- 
times results from pressure upon the abdomen. Certain oc- 
cupations, as those of tailors and shoemakers, are prone to 
produce this affection. Tight lacing is also an important 
factor. It is most frequently encountered in adult life, occurring 
more frequently in women than in men. Chest deformities 
(kyphosis) may give rise to the condition. Repeated preg- 
nancies may cause relaxation of the abdominal Avail and thus 
be causative elements. It is associated with neurasthenia. 
Traumatism, chronic diseases giving rise to emaciation, peri- 
toneal adhesions making traction upon the stomach, and the 
removal of large abdominal tumors are sometimes etiologic 
factors. 

Symptoms. — The disease may exist without giving rise to 
symptoms. When symptoms arise they are generally due to 
functional disturbances of the organ, gastric atony taking 
place. There is often' diminished gastric secretion, with 
symptoms of nervous dyspepsia. Upon inflation, the stomach 
is noted to be of normal size, but displaced. Constipation 
and colicky pains in the abdomen are often important features. 

Prognosis. — The prognosis greatly depends upon the 
etiologic factor. 

Treatment. — The treatment consists in the removal of the 
cause, if possible, and in massage, electricity, proper food, 
bitter tonics, and remedial agents which improve the general 
constitution. Constipation should be relieved by suitable 
remedies. 



474 DISEASES OF THE DIGESTIVE TRACT. 

OTHER DISPLACEMENTS. 

The stomach may be displaced to the right, to the left, or 
upward, from the pressure of tumors, or abdominal enlarge- 
ments. Deformities of the stomach are sometimes found, 
such as the "hour-glass contraction." The organ maybe ver- 
tical, and rarely the greater part of the stomach is on the right 
side in the condition known as transposition of the viscera. 

NEUROSIS OF THE STOMACH. 

This may consist in increase or diminution of sensibility, in 
the increase or diminution of contractility, or in the increase or 
diminution of secretions. The so-called nervous dyspepsia is 
an important form of neurosis. 

GASTRALGIA. 

The condition consists in severe boring, rumbling, painful 
contraction in the epigastric region, extending from the 
xiphoid cartilage and radiating to the back, accompanied by 
syncope and signs of collapse. The condition may appear 
suddenly, without apparent cause, or may be due to slight 
pressure in the epigastrium. It may be accompanied by the 
sensation of the globus hystericus, bulimia, frequent micturi- 
tion, and vomiting. It disappears after having lasted but a 
few moments. The attacks occur with marked irregularity, 
occasionally several taking place in one day, upon alternate 
days, or not recurring for months. Gastralgia is important 
on account of the attack sometimes simulating other affections, 
particularly intercostal neuralgia, ulcer of the stomach, attacks 
of hepatic colic, nephralgia, and enteralgia, and the gastric 
crisis of locomotor ataxia. The diagnosis of gastralgia should 
never be made unless these diseases can be excluded. 

BULIMIA. 

This may occur in association with the sensation of an 
empty stomach. There is a constant desire for food without 
satisfying the appetite, the sensation being accompanied by 
headache, palpitation of the heart, and syncope. 

NEUROSIS OF SECRETION* 

Hyperchlorhydria or hyperacidity. 

This condition is exceedingly common in ulcer of the stom- 
ach, but may occur as a neurosis. 



INTESTINAL CATARRH. 4/5 

The diagnosis depends upon the examination of the gastric 
contents. It may be produced by highly seasoned foods, in 
alcoholic intoxication, and sometimes from great anxiety. 

Symptoms. — The symptoms consist in pressure and full- 
ness in the epigastrium after meals, occasionally accompanied 
by pain, acid eructations, cardialgia, pyrosis, and sometimes 
bulimia. Vomiting is rare. 

The condition should only be diagnosticated when ulcer of 
the stomach can be excluded. 

PERISTALTIC UNREST OF THE STOMACH, 

This condition was first described by Kussmaul. 

The continuous and repeated contractions of the muscles of 
the stomach are most marked after meals, and also occur 
in the interval between meals. Belching and eructation 
may occur. This condition can often be ~ seen by inflation. 
Occasionally, painful contractions of the cardia and pylorus 
take place. 

DIMINISHED PERISTALSIS OF THE STOMACH, OR ATONY. 

Pyloric relaxation is a rare form of neurosis, and when it 
occurs the undigested gastric contents enter the intestinal 
canal. 

Relaxation of the cardiac orifice gives rise to eructation, 
and regurgitation of food. 

Prognosis. — The prognosis is favorable if the underlying 
cause can be removed. 

Treatment. — The treatment consists in removing the un- 
derlying cause if possible. Change of scene, a long ocean 
voyage, and tonic treatment are of value. 



DISEASES OF THE INTESTINES. 

INTESTINAL CATARRH. 
ACUTE AND CHRONIC CATARRHAL ENTERITIS. 
Definition. — Acute catarrhal enteritis is an acute inflamma- 
tion of the intestinal mucous membrane. 

The condition is occasionally local, due to the inflammatory 
process involving limited parts of the bowel. 

Synonyms. — Acute inflammation of the intestines ; acute 
intestinal catarrh. 



4^6 DISEASES OF THE DIGESTIVE TRACT. 

Etiology. — The disease may be primary or secondary. It 
is primary when due to errors of diet. Coarse food imper- 
fectly masticated produces an inflammation in the stomach 
(gastritis), followed by an inflammatory condition in the intes- 
tinal tract known as enteritis. This inflammatory condition, 
although acute, is almost always confined to the mucous 
membrane, constituting intestinal catarrh. Unripe fruits and 
badly cooked vegetables are often causes, especially during 
the hot seasons. Spoiled meat, fish, and milk and ice cream 
that have become tainted with parasitic fungi, frequently excite 
violent catarrhal enteritis. Beer and wines that have under- 
gone unhealthy fermentation, and excessive drinks of cold 
water, especially bad, foul water mixed with sewage, give rise 
to the condition. The affection may be due to sudden chill- 
ing of the body, especially during a copious perspiration, as 
from a plunge into cold water Avhile sweating is going on. 
Traumatism may play some part in the etiology. Falls, 
blows, and kicks of the abdominal wall may cause the dis- 
ease. Foreign bodies may act in the same way. Large gall- 
stones, fecal masses, long-continued constipation, parasites 
such as intestinal worms, various micro-organisms, chemic 
substances such as the alkalies, mineral acids, corrosive sub- 
limate, arsenic, and so on, may be causative factors. 

The specific micro-organisms play an important role, espe- 
cially the comma bacillus of Koch. The extremes of age are 
particularly liable to acute inflammatory conditions of the 
bowels. It is not quite clear how nervous influences affect 
the intestinal mucous membranes, but the observation has 
been repeatedly made that emotion, fright, and anger cause 
acute catarrhal enteritis. 

Among the secondary causes are inflammations of the con- 
tiguous parts — for instance, peritonitis causes intestinal catarrh. 
Eczema of the anus may extend into the rectum. Injury to 
the mucous membrane, as from bougies or other foreign 
bodies, may excite catarrhal inflammation. Compression of 
the intestines from the growth of tumors, circulatory disturb- 
ances, especially those relating to the portal circulation, also 
conditions which relate to the heart and lungs, may give rise 
to intestinal catarrh. The disease commonly occurs in asso- 
ciation with pulmonary tuberculosis, renal disease, malarial 
cachexia, syphilis, Addison's disease, cancer, and profound 
anemia. 

Pathology. — The inflammation may be limited to a part or 



INTESTINAL CATARRH. 477 

may involve the whole of the small intestine. When limited to 
the duodenum, it is called duodenitis ; to the jejunum, jejnnitis ; 
to the ileum, ileitis ; to the colon, colitis ; and to the rectum, 
proctitis. In the greater number of cases the whole intestinal 
mucous membrane is involved. The surface of the intestines 
is found swollen and hyperemic, and there is a thick layer of 
mucus on the surface. The lymph-follicles, both solitary 
and agminated, may reveal some hyperplasia and become 
prominent, and even slight ulceration of the lymph-follicles 
may be present. Microscopically, the epithelial cells are 
swollen and granular, many being desquamated from the 
basement membrane. There may be some leukocytic infiltra- 
tion into the submucosa, and proliferation of the lymph-nodes. 
The blood-vessels will be seen to be engorged. In some 
instances catarrhal inflammation can not be demonstrated 
at the autopsy. 

Symptoms. — Two forms may be recognized clinically, the. 
acute and the chronic varieties, the most important symptom 
of either variety being diarrhea, which may indeed be the only 
manifestation of the disease. The condition may even exist 
without diarrhea, especially if the jejunum be alone affected. 
The stools vary greatly in character, the color depending chiefly 
upon the amount of bile. If bile is present in large amounts, 
the stools may be dark brown ; in less amounts, the stools are 
light yellow ; and if bile be absent, they are of a grayish- 
white tint. They are thin and watery, and occasionally pul- 
taceous. If portions of undigested food are seen in them, 
with small amounts of flakish mucus, the condition is known 
as lienteric diarrhea. 

Microscopically, the stools contain micro-organisms, crystals 
of phosphate of lime, cholesterin, Charcot-Leyden crystals, 
epithelium, and mucus. 

Abdominal pain is frequently present in the acute variety. 
It may be colicky in nature, and if the colon be involved, tor- 
mina and tenesmus are present. Some tympanitis occurs. 
Borborygmus is noted. Often in the acute forms vomiting is 
a symptom, and a subfebrile temperature is not infrequent. 
Anorexia, with a dry, coated tongue and much thirst, is pres- 
ent in the majority of cases. The number of stools vary from 
four to twenty or more in the course of a day. The acute 
attack may last from two or three days to a week or more. 

The chronic variety frequently follows the acute form, but 
as has been pointed out in the etiology, may be an indepcnd- 



47$ DISEASES OF THE DIGESTIVE TRACT. 

ent affection. Diarrhea, with or without colic, is a symptom, 
especially diarrhea of the lienteric character. In the chronic 
form the general nutrition of the patient suffers, and there may 
be anemia. If there be marked diarrhea, the blood may show 
concentration, the erythrocytes being relatively increased. 

If the inflammation is confined to the small intestine, diar- 
rhea is a less prominent symptom than if it occur in the colon. 
Pain is usually of a colicky nature, the stools are yellowish- 
green in color, and often contain particles of undigested food, 
and do not contain much mucus, blood rarely being present in 
the stools. If the inflammation be confined to the large 
bowel, there may be tenderness over the abdomen along the 
line of the colon. Diarrhea is more apt to be marked, tenes- 
mus prominent, and the stools contain much mucus. Fever, 
if present, is subfebrile in range. It is not possible to diag- 
nosticate inflammations limited to certain areas, such as the 
duodenum, jejunum, or ileum. 

Prognosis. — The prognosis in the majority of cases is favor- 
able, the exceptions being where the disease is due to poison. 
The secondary forms, due to chronic cardiac, renal, or hepatic 
disease, and the cachexias, are not usually amenable to cure. 

Treatment. — The prophylaxis consists in the avoidance 
of tainted food and impure drinking-water. Attempts should 
be made to remove the causes in the secondary forms. Rest 
in bed in the severer forms is important. Very little food 
should be given, this consisting principally of boiled milk and 
concentrated meat juices. Vegetables and fruit should be 
withheld. The salts of bismuth in large doses, from fifteen 
to thirty grains, four or five times daily, combined with small 
amounts of opium, are useful. Preceding the administration 
of the bismuth salts, a brisk purge may be given ; this may con- 
sist in the administration of calomel or castor oil, followed by 
salines. In conditions in which much mucus is present, entero- 
clysis is of value. For the relief of pain, opium suppositories 
may be given. For the thirst, small pellets of ice may be 
grateful, large quantities of fluid being avoided. If vomiting 
be a prominent symptom, food must be entirely withheld. In 
cachectic individuals stimulation by brandy is of use. A 
change of climate, especially in summer, as a residence at the 
seashore or the mountains, is often beneficial in protracted 
cases. 



PHLEGMONOUS ENTERITIS. 479 



CROUPOUS ENTERITIS. 

Synonym. — Diphtheritic enteritis. 

Etiology. — This follows the administration of mercury, 
lead, or arsenic, or it may be secondary to such diseases as 
pneumonia, pyemia, septicemia, and enteric fever, or some 
chronic diseases such as Bright's disease, cirrhosis of the liver, 
and carcinoma. The pseudomembrane caused by the Klebs- 
Loffler bacillus sometimes occurs in the intestines, and this 
should be considered as true diphtheria. Croupous enteritis 
has been known to follow appendicitis. A fibrinous exudate 
may be found upon any part of the mucous coat in the small 
or large intestine. The colon, particularly near the ileocecal 
juncture, is frequently involved. The membrane is grayish- 
white in color, varies in thickness, and usually appears in 
patches. 

Symptoms. — The symptoms are not usually distinctive ; 
they are generally pain and diarrhea, the stools frequently 
containing bloody mucus, and often pieces of pseudomem- 
brane. There may be tenesmus. Fever may or may not appear 
during the course of this affection, or the disease may run 
its course without apparent symptoms. 

Treatment. — The treatment is symptomatic. It is neces- 
sary to relieve pain by means of opium, and to carefully 
restrict the diet. A laxative may be administered from time 
to time when tenesmus is marked. • 



PHLEGMONOUS ENTERITIS. 

Synonym. — Suppurative enteritis. 

This is a rare affection, and frequently occurs with a corre- 
sponding lesion in the stomach. It is also associated with in- 
testinal obstruction, such as intussusception, strangulated 
hernia, also from infected emboli, etc. It may accompany 
carcinoma. Abscesses will be found in the submucosa, and 
when they rupture into the lumen of the bowel a small ulcer 
is produced. 

Microscopically, leukocytes and round cells will be found 
infiltrated in the coats of the intestines, also necrotic areas and 
dilated blood-vessels. 



480 DISEASES OF THE DIGESTIVE TRACT. 



ENTERITIS OF CHILDREN* 

Synonyms. — Summer diarrhea ; infantile diarrhea. 

Etiology. — Clinically, three forms have been described — 
acute dyspeptic diarrhea, cholera infantum, and acute enterocolitis. 
The disease occurs more frequently during the hot- season, es- 
pecially in artificially fed children, between the ages of six and 
eighteen months. The disease appears most often among the 
poorer classes. 

Pathology. — The mucous membrane of the large and the 
small intestine usually shows catarrhal inflammation. The 
agminate and solitary lymph-follicles are prominent in many 
of the cases, and in the more chronic varieties superficial ulcer- 
ation may even occur. A fibrinous exudate on the mucous 
coat is rarely found. This when present generally affects the 
lower part of the ileum and the colon. In many instances the 
spleen is enlarged. The blood shows anemia, and as a result 
of the profuse diarrhea the liquid parts of the blood are de- 
creased, the erythrocytes relatively increased (blood concen- 
tration). Various forms of micro-organisms are associated 
with the diarrheas of children. Booker has described a number 
of varieties of the bacillus coli communis. The bacillus lactis 
aerogenes is by many considered an important factor in the 
causation of this affection. The bacillus proteus vulgaris and 
others are also associated with these diarrheas. 

ACUTE DYSPEPTIC DIARRHEA. 

The disease usually begins with slight restlessness and an 
increase in the number of stools, which contain undigested 
food and curds, and are very often offensive. Occasionally, 
the disease begins abruptly with abdominal colic, pain, vomit- 
ing, and fever, the temperature often reaching 104 F. or 
105 ° F. These symptoms may be preceded by convulsions. 
Upon palpation the abdomen is painful, and the child's thighs 
are frequently flexed upon the abdomen. The stools may 
be grayish or greenish yellow, mixed with undigested food 
and milk curds. In older children these attacks often follow 
the ingestion of unripe fruit or tainted milk. This condition 
may precede the onset of some of the specific fevers, especially 
those occurring during the hot months. In a weak child even 
mild attacks may prove fatal. In older and well-nourished 
children, with proper treatment, the attacks are most often 
curable. 



ENTERITIS OF CHILDREN. 48 I 

CHOLERA INFANTUM. 
This condition is not nearly so common as was formerly 
supposed. According to Holt, it occurs in but two or three 
per cent, of all the summer diarrheas. It arises in the hot 
months, and most frequently in artificially fed children that 
have had some previous bowel derangement. The important 
symptoms are vomiting, profuse diarrhea, and tendency to col- 
lapse. The disease often begins with persistent vomiting, ag- 
gravated by attempts to take food or drink. At first the stools 
are very offensive, containing fecal matter, brown or yellowish 
in color, later becoming thin, watery, and serous, and losing 
their odor completely. The surface temperature may be low, 
but the rectal temperature will always show high fever. The 
child soon manifests the symptoms of collapse, with marked 
prostration. The eyes are sunken, the features pinched, the 
fontanels depressed, and the skin pale and .ashy. Often there 
is cyanosis, and delirium and restlessness may be present 
during the earlier period of the attack ; later the child becomes 
dull and stupid, and passes into coma. Cheyne-Stokes respi- 
ration may be present. If the child recovers, fever, vomiting, 
and diarrhea cease, and the patient is able to take food and 
retain it. The surface temperature becomes normal and the 
rectal temperature falls. The pulse, which has been extremely 
rapid throughout, becomes slower and fuller. Should the 
attack terminate fatally, the child often dies in coma, with or 
without convulsions. 

ACUTE ENTEROCOLITIS. . 

The attack may follow acute dyspeptic diarrhea, the symp- 
toms of the latter becoming aggravated, the temperature 
rising, the pulse becoming more frequent, the stools showing 
traces of bloody mucus, and the abdomen becoming dis- 
tended and tender in the line of the colon. There may be 
vomiting, but it is not so apt to occur as in cholera infantum. 
If recovery takes place, the diarrhea ceases, and the disease 
may be over in from two to three weeks. On the other hand, 
the disease may become subacute, the fever subsiding, but the 
diarrhea continuing for some time. Another variety occurs, 
in which there is an intense intestinal inflammation, the 
symptoms resembling acute dysentery. This form commonly 
attacks older children. There is tormina and tenesmus, with 
great prostration, and the disease may terminate fatally in 
forty-eight hours. 



482 DISEASES OF THE DIGESTIVE TRACT. 

Prognosis in Enteritis of Children. — As has already been 
mentioned, even simple diarrhea in hot weather, attacking 
artificially fed children, may be a serious disease, much more so 
cholera infantum and acute enterocolitis. Recovery often takes 
place from the two latter conditions under favorable hygienic 
surroundings, good food, and proper treatment. 

Treatment. — Hygienic treatment is of great importance. 
A change from the hot city to the mountains or seashore is 
often sufficient to restore the child to health. If this can not 
be done, open parks or trips upon the water should be sug- 
gested. Fresh air is indicated in all instances. Cool bathing 
is of decided benefit, especially if the temperature of the child 
should rise to 102 F. Iced cloths to the head and abdomen, 
or injections of ice-water into the bowel, have been followed by 
good results. In all cases wherever possible, a wet nurse should 
be procured for a bottle-fed child. If there is much vomiting, 
it is well to withhold food for some little time. Small amounts 
of water or small particles of ice should frequently be given. 
Modified milk is an excellent food for children suffering from 
summer diarrhea. Egg-albumen is also of use. Where 
modified milk can not be procured, sterilized milk may be 
substituted. Mutton, chicken, and beef broths may be given 
in small quantities from time to time. A laxative should be 
administered at once. This may be followed by any reliable 
intestinal antiseptic, such as naphthalin, salol, resorcin, the sali- 
cylates, and the salts of bismuth. These must be given in com- 
paratively large doses. Opium should, if possible, be avoided. 
Alcohol in some form is often necessary for stimulant. 

MUCOUS ENTERITIS- 

Synonyms. — Mucous colitis ; membranous enteritis. 

Etiology. — Attention was first called to this disease by 
Mason Good, in 1825, since which time numerous observa- 
tions have been recorded. The disease consists in character- 
istic colic-like abdominal pain, with peculiarly formed stools, 
consisting largely of mucous masses. The disease is much 
more common among women, some authorities having put 
the percentage as high as from So fo to 90^. In the female 
sex, hysteria and neurasthenia are frequently associated with 
this affection. When the disease attacks males, they usually 
belong to the class known as hypochondriacs. In all cases 
there is a long-standing history of constipation. 



INTESTINAL ULCERATION. 483 

Pathology. — The mucous membrane of the colon reveals 
upon the surface a very tenacious coating of mucus, which 
sometimes separates as a tubular membrane. Microscopic 
examination of the stools reveals them to be made up of 
mucus, many epithelial and pus-cells, and various micro- 
organisms. In some cases the casts are not present, but in- 
stead stringy, ropy mucus is found. The inflammation of the 
coats of the large bowel is not extensive, and the mucus may 
separate without leaving a permanent lesion. 

Symptoms. — The onset of the disease varies greatly ; occa- 
sionally it may be insidious. On the other hand, the disease 
ma}' develop abruptly with the appearance of characteristic 
symptoms which consist in colic-like abdominal pains and the 
appearance of mucous masses in the stools. The pains may be 
exceedingly severe, and are usually felt in the epigastrium and 
in the left iliac fossa. Occasionally the entire abdomen may be 
affected, so that the pain may even be noted in the bladder 
and in the genitalia, or the pain radiates into the left leg, 
accompanied by considerable tenesmus. The characteristic 
stools are passed, followed by cessation of the pain, which may 
be for a longer or shorter interval. The pain may return 
several times in the day, or may only occur for a week, or 
for a month or so. Preceding the attack there are anorexia, 
constipation, and general nervous symptoms, usually with great 
mental depression. Fever is absent ; the pulse is but slightly 
accelerated. 

Prognosis. — As regards life, the prognosis is good. The 
attack may occasionally cease and not return ; in the majority of 
cases, however, the disease is chronic, and not amenable to cure. 

Treatment. — Lately, the condition has been assumed to be 
a neurosis. Irrigation of the bowel with a normal salt solu- 
tion has met with success. Occasionally, it is necessary to 
give castor oil, or a saline or other cathartic during the stage 
of obstinate constipation. If the pains are severe, sinapisms 
to the abdomen, hot baths, and opium are necessary. The 
underlying nervous condition should always be treated, great 
attention being given to the patient's general hygiene. 



INTESTINAL ULCERATION. 

Any part of the intestinal tract may be the seat of ulcera- 
tion, no part of the body revealing ulceration more commonly. 
Ulceration may result from necrotic changes. Simple duode- 



484 DISEASES OF THE DIGESTIVE TRACT. 

nal ulcers are not infrequent. Duodenal ulcer also arises from 
extensive superficial burns. Thrombosis and embolism cause 
intestinal ulceration, and amyloid disease also produces this 
condition. Ulceration from inflammatory processes may occur, 
the most common being of the catarrhal variety. They may be 
follicular, or stercoral which occur in cases of long-standing con- 
stipation. Ulceration may occur in acute infective processes, 
such as enteric fever, dysentery, diphtheria, anthrax, pyemia, 
erysipelas, and variola. Ulceration due to chronic infectious 
disease is met with in syphilis and tuberculosis. It takes place in 
the course of constitutional diseases, such as gout, scurvy, and 
leukemia. It results from toxic conditions, and from malignant 
diseases. 

Symptoms. — The most constant symptom of intestinal 
ulceration is diarrhea, but this may be absent when the ulcer- 
ation is situated high up in the small intestine, or if it be very 
limited. Constitutional symptoms vary greatly, depending 
upon the cause of the ulceration. The stools frequently con- 
tain pus, epithelial cells, shreds of tissue, bacteria, mucus, and 
sometimes blood and undigested particles of food. These find- 
ings depend upon the seat and character of the ulceration. Pain 
also varies as to character and distribution : it may be limited, 
or, if the colon alone is involved, it may correspond to that situ- 
ation. Perforation and hemorrhage may result from ulceration. 
This is more common in the acute varieties than in the chronic. 

Treatment. — The condition should always be considered as 
a symptom, the underlying disease producing the ulceration 
being treated. 

CHOLERA MORBUS. 

Definition. — A disease characterized by severe abdominal 
pain, often colicky in nature, with vomiting, purging, and mus- 
cular cramp. 

Synonym. — Cholera nostras. 

Etiology. — The disease occurs most often in the summer 
months, being favored by bad hygienic surroundings, the eat- 
ing of unripe fruit and vegetables, and exposure to cold and 
wet. It may occur at any age and in either sex. 

Pathology. — No constant anatomic lesions are present. 
Most commonly, catarrhal changes of the intestinal tract will 
be found after death, but in some' instances these are absent. 
Various forms of micro-organisms are associated with this con- 
dition, but no specific one has as yet been discovered. 



ENTERORRHAGIA. 485 

Symptoms. — The onset is abrupt, with severe abdominal 
pain, nausea, vomiting, and diarrhea. At first the vomited 
material may contain partly undigested food, later becoming 
mixed with bile and mucus. The stools at the onset are fecal 
in character, and many evacuations may take place in the 
course of a few hours, after which time they lose their fecal 
character and become serous, not unlike the " rice-water " dis- 
charges of true cholera. There is tenderness upon pressure 
over the abdomen along the region of the colon. Fever is 
almost invariably present, and it may range from ioo° F. to 
106 F. The extremities may be cold, although the rectal 
temperature is raised. The pulse is rapid and feeble, the face 
becomes pale, pinched, and cyanotic, the urine is scanty and 
high colored, often containing albumin ; and in extreme cases 
anuria may be present. Cramps in the extremities are com- 
mon. Thirst is often extreme. 

Differential Diagnosis. — The disease may closely resemble 
Asiatic cholera, and can only be positively differentiated by a 
bacteriologic examination of the evacuations. 

Prognosis. — The disease is rarely fatal. The duration of 
the attack is from a few hours to several days. 

Treatment. — Absolute rest in bed is important. The diet 
should be restricted, and it is preferable that no food be given 
during the early course of the attack, especially while vomit- 
ing is pronounced. When food is necessary, it should consist 
of sterilized milk and animal broths, given in small amounts. 
Local sinapisms or hot turpentine stupes are of great benefit 
in relieving the pain and in allaying vomiting. It may be good 
practice at the onset of the disease, especially if there is a sus- 
picion that it is due to improper food such as unripe fruit, and 
so on, to give a brisk purge. For the thirst, small pellets of 
ice are of benefit. The remedy for the condition is a hypo- 
dermic of morphia. It is rarely necessary to repeat the injec- 
tion. Later, large doses of the bismuth salts, with opium, are 
of use. Solid food should only gradually be resorted to. 

ENTERORRHAGIA. 

Synonym. — Hemorrhage from the bowel. 

Etiology. — The condition arises in severe acute catarrh of 
the bowel, trauma, new growths, cancer, embolism, hyperemia, 
congestion due to diseases of the heart, lungs, and liver, vol- 
vulus, and it results from incarcerated hernia and from obsti- 



486 DISEASES OF THE DIGESTIVE TRACT. 

nate constipation, producing inflammation, from* parasites, 
particularly the anchylostoma duodenale. Local diseases 
of the bowel, aneurysms, arterial or venous, and foreign 
bodies, particularly cholelithiasis, will produce the condition. 
In some infectious diseases, particularly tuberculosis of the 
intestines, anemic conditions, leukemia, scurvy, purpura, hemo- 
philia, severe jaundice, yellow fever, poisoning from phos- 
phorus, malaria, amyloid diseases of the blood-vessels, erysip- 
elas, enteric fever, dysentery, vicarious menstruation (?), and 
in melena neonatorum, this condition arises. 

Symptoms. — The blood loss may be slight or profuse, open 
or concealed. In the open variety, the blood may be either 
vomited or passed by the rectum. The symptoms depend 
greatly upon the quantity of blood lost. Small blood loss 
may give rise to slight or no symptoms. Great blood loss 
produces collapse. The blood may be passed as pure blood 
or mixed with fecal material. If the blood be retained in the 
bowel any length of time, it is apt to be changed by the fluids 
and passed as a thick, tany substance. 

Prognosis. — The prognosis depends upon the cause and 
the amount of blood lost. 

Treatment. — The treatment consists in absolute rest, and 
the withholding of food both solid and liquid. Pellets of ice 
may be given for the thirst. Ice-bags applied to the abdomen, 
and elevation of the foot of the bed, if the hemorrhage be large, 
will be found of value. Opium is the most reliable remedy. 
Small injections of ice-water into the rectum, when the lesion 
is low down, or iced suppositories may be beneficial. 



ENTEROPTOSIS, 

Definition. — A condition in which the attachments of the 
viscera are loosened and there is a dropping of the stomach, 
intestines, very commonly the transverse colon, the liver, the 
kidneys, and sometimes the spleen. 

Synonyms. — Glenard's disease ; visceroptosis. 

Etiology. — The condition may be due to a relaxed abdom- 
inal wall as a result of repeated pregnancies or ascites, or after 
the removal of large abdominal tumors. 

Symptoms. — It may persist without symptoms, being only 
detected by physical examination. In other cases symptoms 
of neurasthenia are present. When occurring in young indi- 
viduals, neurasthenia is usually pronounced. Physical exam- 



APPENDICITIS. 487 

ination may reveal displacement of the various organs enumer- 
ated. Nephroptosis is commonly met with. Displacements 
of the liver and spleen are less frequently encountered, and the 
latter is sometimes quite movable. The colon, especially the 
transverse, is frequently displaced downward. 

Treatment. — A carefully applied abdominal support is often 
of value. Constipation should be corrected. Tonics may be 
of value, and the neurasthenia should be treated. 

APPENDICITIS. 

Definition. — An inflammation of the appendix vermiformis, 
often giving rise to disease of surrounding structures. 

There are no synonyms ; the term typhlitis and cecitis mean 
inflammation of the cecum, perityphlitis meaning inflam- 
mation of the serous coat of the cecum. These forms are dis- 
tinguished with difficulty from appendicitis, but are rarely 
primary affections, usually resulting from inflammation of the 
appendix. In enteric fever the cecum frequently reveals the 
seat of the greatest ulceration, and tenderness in the right iliac 
fossa is present in a large proportion of cases. 

Etiology. — Historic Note. — The appendix is a rudimen- 
tary, functionless organ, being a relic of the large ances- 
tral cecum. In many of the low T er animals the cecum is very 
large and possesses distinctive functions. Darwin clearly 
demonstrates the functionless character of the appendix ver- 
miformis in his work, the " Descent of Man," chapter 1, page 
20, in which he says : " With respect to the alimentary canal, 
I have met with an account of only a single rudiment, namely, 
the vermiform appendage of the caecum. The caecum is a 
branch or diverticulum of the intestine, ending in a culdesac, 
and is extremely long in many of the lower vegetable-feeding 
mammals. In the marsupial koala it is actually more than 
thrice as long as the whole body. It is sometimes produced 
into a long, gradually-tapering point, and is sometimes con- 
stricted in parts. It appears as if, in consequence of changed 
diet or habits, the caecum had become much shortened in vari- 
ous animals, the vermiform appendage being left as a rudiment 
of the shortened part. That this appendage is a rudiment, 
we may infer from its small size, and from the evidence which 
Prof. Canestrini has collected of its variability in man. It is 
occasionally quite absent, or again is largely developed. The 
passage is sometimes completely closed for half or two-thirds 



488 DISEASES OF THE DIGESTIVE TRACT. 

of its length, with the terminal part consisting of a flattened 
solid expansion. In the orang this appendage is long and 
convoluted ; in man it arises from the end of the short caecum, 
and is commonly from four to five inches in length, being only 
about the third of an inch in diameter. Not only is it useless, 
but it is sometimes the cause of death, of which fact I have lately 
heard two instances : this is due to small hard bodies, such as 
seeds, entering the passage, and causing inflammation." 

Also Haeckel demonstrates this in volume n, page 344, of 
his work, " The Evolution of Man," as follows : "In man, as 
in most apes, the beginning of the blind intestine alone be- 
comes wide ; its blind end remains very narrow, and afterward 
appears only as a useless appendage of the former. This 
' vermal appendage ' is interesting in dysteleology as a rudi- 
mentary organ. Its only importance in Man consists in the 
fact that now and then a raisin-stone, or some other hard, in- 
digestible particle of food becomes lodged in its narrow cavity, 
causing inflammation and suppuration, and, consequently, kill- 
ing individuals otherwise perfectly healthy. In our plant- 
eating ancestors this rudimentary organ was larger, and was 
of physiological value." 

Following this line of argument, it is conclusive that the 
most marked predisposing factor is the evolutionary tendency, 
to be distinguished from the hereditary tendency which shows 
itself from generation to generation. The evolutionary ten- 
dency makes its appearance only after changes of environment. 

Predisposing Causes. — (1) The most important is the evo- 
lutionary tendency, and under this heading various abnor- 
malities must be considered. Strictures. — Narrowing of the 
lumen of the appendix prevents the normal drainage of the tube, 
establishing favorable conditions for the growth of micro- 
organisms. This is especially true when the stricture is situ- 
ated near the proximal end, or at the valve which guards the 
opening of the appendix into the cecum, called " Gerlach's 
valve." The strictures may be multiple. In some instances 
the canal is obliterated. (2) Blood Supply. — The blood supply 
of the organ may be defective, causing anemia, and in this way 
predisposing the organ to infection. This may also be brought 
about by the free mobility of the appendix, thereby twisting 
the blood-vessels in a long meso-appendix, and thrombosis 
may occur in the artery. Atrophy of the appendicial walls 
may be present from the diminished blood supply and from 
the pressure of fecal concentration occupying the lumen. The 



APPENDICITIS. 489 

latter, however, frequently produces atrophy of the walls. 
(3) Position and Size of the Appendix. — The most common posi- 
tion of the organ is pointing in the direction of the spleen, and 
next in frequency is its position behind the cecum. It may ex- 
tend over the brim of the pelvis, or toward the umbilicus. It 
has been found in the inguinal canal, also in the intussuscep- 
tional portion of the colon in cases of intussusception. It fact, 
it may be stated that the appendix may occupy various posi- 
tions. The organ varies greatly as to length and diameter ; 
however, it usually measures about seven or eight centimeters. 

The histology of the appendix closely resembles that of the 
cecum. The submucosa is freely supplied with lymph-follicles ; 
the muscular coats are usually not well developed. Occasion- 
ally the appendix is absent altogether. 

The majority of cases of appendicitis develop in young 
persons ; however, it has been met with in the extremes of 
age. It is more prevalent in the male than in the fe- 
male sex. In occupations requiring exertions that produce 
marked contraction of the abdominal muscles, and hence com- 
pression of the abdominal contents, fecal or gaseous matter 
may be forced into the lumen of the appendix, which may pre- 
dispose the organ to infection. Diarrhea is also a predispos- 
ing cause, especially when there is inflammation of the cecum. 
Constipation is a predisposing cause. 

The appendix may be involved from extension of inflamma- 
tion. Indiscretion of diet, such as eating highly seasoned 
foods, overeating, or excessive drinking may produce inflam- 
mation. Many of the infectious diseases predispose, especially 
influenza, diphtheria, enteric fever, tuberculosis, the rheumatic 
diathesis, and the eruptive fevers. One attack, far from con- 
ferring immunity, predisposes to other attacks, and in this dis- 
ease relapses are common. 

Exciting Causes, — The most important of the exciting causes 
are micro-organisms ; the most common of these, which pro- 
duces inflammation, is the bacillus coli communis. Many other 
micro-organisms, such as the bacillus typhosus, the micrococ- 
cus lanceolatus, the staphylococci, the tubercle bacillus, the 
streptococcus, the bacillus pyocyaneus, and others have been 
known to be associated with the affection. 

Bodies in the lumen of the appendix often act as exciting 
agents, the most common being the fecal concretions, these 
causing an erosion of the walls, sometimes with perforation, or 
allowing micro-organisms to set up inflammation. Foreign 



49° DISEASES OF THE DIGESTIVE TRACT. 

bodies, such as grape seeds, date seeds, apple pits, stones of 
various fruits, hair, and small pieces of wood, and, in a case de- 
scribed by Deaver, a pin perforated the wall of the appendix 
have given rise to the affection. Foreign bodies, however, 
form a very small percentage as direct causative factors of 
the affection, but are predisposing causes. 

Traumatism may be an exciting cause. The appendix may 
be diseased as a result of extension of inflammation, especially 
from the cecum. 

Pathology. — The pathology of appendicitis may be said to 
present various phases met with in inflammation. In many 
cases a simple acute catarrhal inflammation is encountered ; 
again, this may be chronic catarrhal inflammation. Interstitial 
inflammation, frequently involving all the coats, is found, or 
in this form ulcerative appendicitis is common, the ulcer being 
either deep or superficial. In some instances it may perforate. 
The interstitial inflammation may give rise to phlegmonous and 
gangrenous appendicitis, this usually being preceded by inter- 
ference with the circulation of the organ. Abscess formation 
may follow. There may be chronic interstitial inflammation 
known as "fibroid appendicitis" or "appendicitis obliterans" 
resulting either from repeated attacks of acute catarrhal or acute 
interstitial inflammation. This frequently gives rise to the devel- 
opment of stricture, which in turn predisposes to acute attacks. 
Extensive retroperitoneal abscesses often result from appendicitis. 
These are frequently in the flank, and may form large peri- 
nephritic abscesses. The psoas muscle may also be invaded 
by pus. As a result of necrosis and sloughing of the appen- 
dix, this organ may be completely destroyed, and it is not 
uncommon to find at the operation that a single and small 
slough represents the remains of the appendix. A fibroid 
change may begin at the distal end of the appendix and ex- 
tend toward the proximal extremity, obliterating the lumen 
known as appendicitis obliterans (the term first used by Senn). 

The formation of new connective tissue in the walls of the 
appendix may be so pronounced as to cause atrophy of the 
muscular, submucous, and mucous coats, and if the internal 
pressure be marked, dilatation of the lumen results, with thin- 
ning of the walls. 

As a result of acute inflammation, the peritoneum may be 
involved by extension, or the serous membrane may become 
inflamed as a consequence of perforation. The peritonitis 
which follows appendicitis may he local or general. As a rule, 



APPENDICITIS. 491 

the inflammation is confined to the right iliac fossa, and abscess 
formation not infrequently results when the inflammation is 
confined to this area ; however, if the appendicitis be situated 
so that the greatest point of inflammation be away from the 
right iliac fossa, abscess may arise in this situation, and such 
abscesses are sometimes met with in the pelvis or in the flank. 
Again, the appendix has been known to perforate into the blad- 
der. The cecum often is secondarily involved in acute in- 
fective appendicitis, particularly if the organ be situated in 
close relation. 

Hemorrhage sometimes results, either from necrosis of the 
appendicial arteries, or from ulceration of the internal iliac 
or the deep circumflex artery ; superficial pylephlebitis may 
arise from inflammation of the appendix, this inflammation not 
infrequently extending into the liver, or infected emboli may be 
carried into the liver and produce abscesses in this organ. 

Symptoms of Acute Appendicitis. — The onset is sudden. 
There is pain in the abdomen, which at first maybe general or 
centered around the umbilicus, and occasionally in the epigas- 
trium and in the left or right iliac fossa. In many of the cases 
the pain is confined to the right iliac fossa and directly in the 
region of the appendix. If the pain is general or confined to 
various parts of the abdomen, it soon localizes itself to the 
right iliac fossa, usually within the course of twenty-four hours. 
It is paroxysmal, or intermittent, and colic-like. In some 
instances it is sharp and intense, particularly if it involves the 
peritoneal coat ; this has been called serous membrane pain. 
In other cases, especially when the serous coat has not been 
involved, the pain is dull, and called "connective-tissue pain" 
Pain is the most constant of all the symptoms. It may be 
preceded by chilliness ; frequently nausea and vomiting mark 
the beginning of the attack. Fever rapidly follows the onset 
of the disease, which is usually moderate, varying from ioo° F. 
to 103 F.; however, it may be absent in some cases. When 
local suppuration results, the fever may be marked and of a 
septic type. When general peritonitis sets in, the temperature 
maybe of the septic type, or in some instances remain normal. 
The frequency of the pulse generally corresponds to the degree 
of the fever. The surface temperature is sometimes higher 
over the right iliac fossa than the left. Constipation is com- 
monly present in this disease, but in some instances there is 
diarrhea. The tongue is coated posteriorly with a moist fur. 
The urine gives the characteristics of febrile conditions. It 



492 DISEASES OF THE DIGESTIVE TRACT. 

may be albuminous ; frequent micturition is a symptom in 
some cases. 

Physical Examination. — Inspection. — The facies shows suf- 
fering. The expression is anxious, the patient carefully noting 
and observing his condition. The position of the patient is 
often characteristic — the right thigh is most frequently partially 
flexed upon the abdomen, while the left leg is extended. On 
examination of the abdomen, slight distention is noted. The 
breathing is shallow and thoracic. 

Palpitation. — On palpating the abdomen the right rectus 
muscle will be found rigid ; sometimes this rigidity also exists 
in other abdominal muscles. It is present if the patient comes 
under observation early in the course of the attack ; later, it 
commonly disappears. Tenderness is as constant as pain. It 
is usually localized to " McBurney's point" (a point at the in- 
sertion of the line drawn from the anterior superior spinus pro- 
cess of the ilium to the umbilicus, and another along the right 
edge of the rectus muscle). This tenderness is noted either 
upon superficial or deep palpation ; however, the point of 
greatest tenderness is not always in the region described by 
McBurney, but in other situations, and may be said to corre- 
spond to the point of the maximum intensity of the inflam- 
mation. Pressure upon the opposite side frequently produces 
pain in the region of the appendix. If the primary rigidity has 
subsided, a tumor is often palpable in the right iliac fossa, 
which may vary in size. In some instances the appendix may 
be clearly made out. Examination per rectum and per vagi- 
nam frequently reveals tenderness in the inflamed area when 
pressure is made in that direction. 

Percussion. — If a tumor exists there is dullness upon percus- 
sion. 

Local Abscess Formation. — The symptoms just enumerated 
may subside, or in some instances they become aggravated. 
The fever becomes higher and often of a septic type ; the pulse 
rapid and feeble ; and chills and sweating may occur. The 
pain becomes dull, less severe, and often disappears. Upon 
inspection, in some cases local redness and edema are noticed. 
Upon palpation the rigidity of the abdominal muscles is not 
present, and a large mass may be clearly demonstrated, the 
most frequent situation being in the right iliac fossa lying upon 
the psoas muscle ; however, the abscess may be present in the 
flank or just above Poupart's ligament, and sometimes in 
other situations. 



APPENDICITIS. 493 

Complications and Sequels. — Gangrene and perforation 
of the blood-vessels and neighboring tissues may occur. Per- 
foration is a frequent complication. It is recognized by signs 
of collapse, and fall in the temperature, rapid running pulse, 
great tympany, and obliteration of the lower border of liver 
dullness. Peritonitis is a serious complication. It is most 
often local, and limited to the region of the appendix ; it 
may, however, be general. General peritonitis is the most 
frequent cause of death. Persistent vomiting is an exceed- 
ingly serious complication of appendicitis. (For symptoms 
see Peritonitis, p. 506.) The gravity of this disease lies 
in the fact that the peritoneum may be involved, and the 
early symptoms may indicate a widespread infection of this 
serous membrane. Hiccup is a distressing symptom, and is 
often due to general peritonitis, and frequently precedes the 
fatal issue. Pylephlebitis and hepatic abscess are grave com- 
plications. The lungs, pleura, and heart are rarely involved. 
Hemorrhage from involvement of the iliac arteries or veins, or 
from the very close position of the mesenteric or ovarian 
veins, may produce a disastrous result from an extension of 
the gangrenous process from the appendix. Intestinal 
obstruction is an important complication. 

CHRONIC APPENDICITIS. 

There may be constant pain of a dull character in the right 
iliac fossa, persisting for long periods of time without fever or 
other general manifestations. Tenderness is present in the 
right iliac fossa. The appendix may or may not be palpable. 
The pain is sometimes aggravated by taking food. 

RELAPSING APPENDICITIS. 

After an acute attack the symptoms may subside, and the 
patient regain complete health. Sooner or later, however, 
another attack follows, the period of recovery varying greatly, 
sometimes extending over a period of months or even years. 
The second attack is generally more severe, but in some 
instances is of a milder character. Again, recovery may fol- 
low, or the attack may prove fatal. A number of these 
attacks are not infrequent in some cases. It may be said that 
after one attack of appendicitis recurrence is the ride. 

Diagnosis. — The direct diagnosis of appendicitis depends 
upon the sudden onset of the disease, of pain in the right 
iliac fossa, tenderness in this region, rigidity of the right rectus 



494 



DISEASES OF THE DIGESTIVE TRACT. 



muscle, vomiting, fever, and in 
tumor. 

Differential Diagnosis. 1 — 



many instances a palpable 



Pain. 



Appendicitis. 
Colicky, radiating 
over the lower 
part of the ab- 
domen toward 
the umbilicus ; 
tenderness over 
"McBurney's 
point." 



Vomiting. 



Usual, but not ex- 
treme. 
Symptoms Relat- Absent. 
ingto the Blad- 
der and Testi- 
cle. 
Urine. Normal. 



Jaundice. 



Absent. 



Biliary Colic. 
Radiating over the 
upper half of the 
abdomen and to- 
ward the right 
shoulder ; tender- 
ness over the gall- 
bladder. 



Pronounced and per- 
sistent. 
Absent. 



May contain bile. 
Present. 



Renal Colic. 

Radiating less over 
the abdomen, but 
down the ureter to 
the testicles, head 
of the penis, and 
often irritating the 
rectum ; tenderness 
over the kidney and 
lumbar region. 

Present, but not per- 
sistent. 

Marked. 



May contain blood 

and mucus. 
Absent. 



Typhoid fever should not be confounded with appendicitis, 
for its onset is insidious, marked by pronounced tenderness in 
the right iliac fossa, a typical temperature curve, and the char- 
acteristic eruption, with enlargement of the spleen ; however, 
when perforation in the course of enteric fever is the first 
symptom brought to the notice of the physician, the diagnosis 
may be difficult. It must also be remembered that appendi- 
citis may be a complication of enteric fever. Inflammation of 
the tubes, ovaries, and pelvic peritonitis may closely simu- 
late appendicitis, but the history of the patient and local 
examination in most cases reveal the true nature of the affec- 
tion. Hysteria may resemble acute appendicitis, and is some- 
times with difficulty diagnosticated from this condition. 

Prognosis. — There is much uncertainty as to the prognosis 
of appendicitis. Much depends upon the involvement of the 
peritoneum, the prognosis being more unfavorable in this con- 
dition. Recurrence of attacks is common. Spontaneous 
recovery from the obliteration of the lumen of the appendix 
may occur, but this is infrequent. 

Treatment. — This had better be considered a surgical 
affection. The surgeon should be promptly called. Osier 
says he is often called too late, but never too early. Rest 
in bed is important. The diet should be restricted, and 



1 Modified from Loomis-Thompson's System, by McNutt. 



INTESTINAL OBSTRUCTION. 495 

nutriment given in small amounts ; in many instances the food 
had better be withdrawn until vomiting subsides. Small pellets 
of ice are given to allay thirst. Opium may be administered 
to relieve pain. Ice applied locally is of great value in reliev- 
ing the pain, and this method had better be practised before 
the diagnosis is made certain. Purging by calomel and salines 
should be resorted to very early. 

INTESTINAL OBSTRUCTION. 

Intestinal Obstruction Due to Strangulation. — This is a 
frequent form of intestinal obstruction. It may result from 
adhesions of the peritoneum. Appendicitis causes adhesions. 
Mesenteric and omental hernia, adhesive tubes, peritoneal 
pouches (Meckel's diverticulum), and pedicular tumors may 
cause the condition. It often follows operation upon the 
abdomen, being due to bands of adhesion. The condition 
is most frequently met with in males, the greater number of 
cases occurring in early adult life. The small intestine is 
more commonly involved than the large. 

Intestinal Obstruction Due to Twists and Knots, Called 
Volvulus. — This is frequently associated with an unusually 
long mesentery, and a very common site is in the sigmoid 
flexure, the next in frequency being the cecum. The intestine 
is usually twisted upon its long axis, thereby causing strangu- 
lation. It is more prevalent in males, and between the ages 
of thirty and forty. 

Intestinal Obstruction Due to Strictures and Tumors. — 
These forms of obstruction usually give rise to symptoms of a 
chronic nature. The obstruction may be due to congenital 
narrowing or complete obliteration of the lumen, such as an 
imperforate anus. It may be due to a cicatricial contraction 
as the result of ulceration, particularly from syphilis, tubercu- 
losis, and dysentery. Tumors of the intestine not infrequently 
cause obstruction, particularly carcinoma, papilloma, adenoma, 
lipoma, and fibroma. Tumors pressing upon the wall of the 
intestine may give rise to the condition, or in rare instances 
pressure from the distended coil of intestine pressing upon a 
neighboring coil may cause the obstruction. 

Abnormal contents of the intestine may produce obstruc- 
tion, such as foreign bodies, particularly coins, pins, needles, 
false teeth, fruit-stones, and intestinal worms. Some drugs, 
such as magnesia and bismuth, when taken in large amounts 



496 DISEASES OF THE DIGESTIVE TRACT. 

accumulate in the bowel and cause obstruction. Fecal impac- 
tion, gall-stones, and enteroliths may occlude the intestinal 
lumen. 

The symptoms of intestinal obstruction may be divided into 
acute and chronic. 

Symptoms of Acute Intestinal Obstruction. — The onset of 
the attack is sudden in the majority of instances, no exciting 
cause being apparent. The first symptom is severe abdominal 
pain, localized around the umbilicus ; however, it may occur in 
any part of the abdomen. It is constant, and liable to exacerba- 
tions. Sooner or later, tenderness of the abdomen develops, with 
symptoms of collapse, great depression, pallor, feeble pulse, 
cold sweat over the face, body, and extremities, nausea, and 
vomiting. Vomiting occurs early ; it often consists of the con- 
tents of the stomach, then becomes bilious, and finally brownish 
and offensive, being composed of fecal material (stercoraceons 
vomiting). Constipation is the rule from the beginning; how- 
ever, there may be an evacuation of the intestinal contents below 
the seat of the stricture. The belly is distended and tympanitic. 
The tongue is coated, and thirst is intense. The amount of urine 
is diminished. There may be some rise in temperature in the 
beginning, but the temperature soon becomes subnormal as 
collapse occurs. If the condition remains unrelieved, the 
symptoms persist, and signs of septic poisoning, which are so 
common as a terminal event of acute peritonitis, appear. De- 
lirium may be present, but as a rule consciousness is retained 
to the last. Vomiting persists to the end. The majority of 
cases, if not relieved, terminate fatally in from six to seven 
days. 

Symptoms of Chronic Intestinal Obstruction. — The onset 
is gradual and the progression of symptoms irregular. Ab- 
dominal pain occurs paroxysmally, often provoked by food, 
and frequently ascribed to indigestion. The pain is not so 
severe as in the acute forms. The attacks finally become more 
frequent, of longer duration, and of increased severity. Some 
vomiting, constipation, less commonly diarrhea, with more or 
less uneasiness within the abdomen are present. The vomiting 
is slight at first, and not persistent, but nausea and disinclination 
for food may exist throughout. At first the constipation is 
not absolute, the patient being relieved by laxatives ; drugs, 
however, act with less and less effect, and occasion more pain 
and vomiting. Occasionally there may be spurious diarrhea, 
due to catarrh in the bowel excited by retained fecal matter 



INTESTINAL OBSTRUCTION. 497 

below the obstruction. It is especially apt to occur when the 
stenosis is low down in the colon. The tongue is coated with a 
white fur and the breath is particularly offensive. The amount of 
urine is normal, and the temperature is most often undisturbed. 
The belly becomes more and more distended as the disease 
advances, a tumor often being discernible. This may be due 
to the accumulation of feces above the obstruction. Visible 
coils of the intestine may be seen in active movement through 
the apparently thin abdominal walls. Upon movement of these 
coils of intestine, pain is aggravated. Borborygmi are common. 
Death in these cases may occur in six months after the onset 
of the symptoms. 

Diagnosis. — The diagnosis of intestinal obstruction must be 
made from obstruction resulting from hernia, the latter in some 
instances being concealed. Examination of the patient is nec- 
essary to reveal the condition. Intestinal obstruction may be 
confused with appendicitis. In the latter,- fever is a pronounced 
symptom, pain is localized to the right iliac fossa, consti- 
pation is not complete, and vomiting occurs early and is not 
likely to become stercoraceous. There is also less distention 
of the abdomen. 

Differential Diagnosis. — 

Obstruction in the Small Intestine. Obstruction in the Large Intestine. 

The symptoms at the onset are most Most often chronic ; volvulus of the 

often acute. sigmoid flexure very acute. 

Pain appears earlier, is more pro- Pain is less marked. 

nounced, and more severe. 

Vomiting appears earlier ; is more dis- Vomiting is more irregular ; may be 

tressing, and more persistent ; vom- slight ; rarely stercoraceous. 

ited matter is more copious, and is 

influenced by taking food. 

Constitutional disturbances most Constitutional disturbances slight ; 

marked ; shock frequent. shock infrequent. 

Meteorism occurs late, and is seldom of Meteorism occurs early, and is well 

high grade. marked. 

Prognosis. — In acute intestinal obstruction the prospect for 
relief is very slight, except in the rarest instances. All cases, 
if not treated, terminate in death. Death may occur in from 
two to seven days, and in the subacute form in from seven to 
thirty days. Cases of chronic obstruction may extend over a 
period of many months. Ulceration, perforation, and general 
peritonitis may be the cause of death, or a coil of the gut may 
become gangrenous. In a small proportion of cases death is 
due to septic pneumonia. 

Treatment. — The treatment is surgical. Opium should be 
32 



49$ DISEASES OF THE DIGESTIVE TRACT. 

given to relieve the pain. If vomiting be persistent, the stom- 
ach-tube may be used, the stomach-contents siphoned, and the 
organ washed. Purgatives should be avoided. Hot turpentine 
stupes may be applied to the abdomen, usually giving relief. 
Ice-bags may allay the pain, but when collapse occurs, ice 
should not be used. In chronic obstruction opium is neces- 
sary for the pain. Rectal feeding may be resorted to. Sur- 
gical interference sooner or later becomes imperative . 



INTUSSUSCEPTION OF THE BOWELS* 

Definition. — " Intussusception consists in the entrance of 
one portion of the intestine within another by an infolding of the 
bowel so that the external fold insheathes the inner." (Lyman 
in Loomis-Thompson's System.) 

The upper portion of the bowel is almost always invaginated 
into the lower, so that the lowermost portion insheathes the 
upper portion. Upon cross-section of the telescoped bowel, 
three - layers of the intestine are found — the outermost, or 
receiving layer, called the intussuscipiens ; the middle layer, or 
returning portion, and the innermost portion, called the enter- 
ing layer. The middle and internal layers together are called 
the intiissusceptum. 

Etiology. — Increased peristalsis. Sometimes it results from 
normal peristaltic movements. It may arise from spasm or 
paralysis of the intestines, and it is sometimes associated with 
carcinomatous growths, or inflammatory conditions of the in- 
testine. Obstinate constipation and chronic diarrhea seem to 
predispose. It has been known to follow trauma. It is most 
frequently met with in children, and is more prevalent in the 
male than the female sex. 

According to Leichtenstern, who recorded 593 cases of in- 
tussusception, 131 cases occurred in the first year of life; 
among these, 80 took place from the fourth to the sixth month ; 
49 cases occurred between the second and the fifth years of life. 
Pilz recorded 162 cases in children, in which 91 took place in 
the first year of life, 7 1 occurring between the second and the 
fourteenth years of life. 

Pathology. — Intussusception may occur at any part of the 
intestine, but is most common in the ileocecal or ileocolonic 
region, involving in this position the ileum and the cecum. It 
may involve the ileum alone, when it is called ileac invagina- 
tion, or the jejunum, when it is called jejunum invagination, or 



INTUSSUSCEPTION OF THE BOWELS. 499 

the colon alone, when it is called colonic invagination. Upon 
postmortem examination the condition of the intussuscepted 
bowel is quite characteristic in its appearance. If death result 
early from shock, the involved area simply reveals the tele- 
scoped bowel ; most frequently, the affected portion is swollen 
and reddened, the peritoneum revealing inflammatory changes. 
The bowel may be gangrenous, and hemorrhage into the 
lumen of the intestine is frequently found. The intussus- 
ceptum usually shows more marked inflammation than the in- 
tussuscipiens, for the reason that the blood supply is more 
or less cut off. The innermost portion of the bowel may 
reveal marked sloughing and complete separation in some in- 
stances. Recovery has resulted from the occurrence of 
separation of the telescoped bowel, healing of the bowel taking" 
place at the point of separation with the lower end of the 
intestine. Perforation and general peritonitis may occur. 

Symptoms. — The condition begins suddenly in the midst 
of health, with pain, usually of a colicky nature, localized to the 
abdominal region, and the abdomen becomes distended. This 
may occur during sleep. In rare instances the onset may be 
more insidious. In children it maybe ushered in by a loud cry 
or by convulsions. The pain may be localized at a particular 
point and radiate from there. Vomiting is a frequent, although 
not an invariable, symptom. The vomited material may con- 
sist of fecal matter. Constipation is the rule, accompanied by 
considerable tenesmus. Frequently in the stool, blood and 
mucus are present. Soon symptoms of collapse develop ; 
the pulse becomes small, rapid, and feeble. The vomiting 
recurs, bloody mucoid discharges from the bowel may con- 
tinue, and the abdomen becomes tympanitic. These symp- 
toms may soon be followed by death. In some cases remis- 
sions may occur and the condition become more or less 
chronic. In these cases the pain is usually milder, and vom- 
iting and bloody diarrhea may be absent altogether. Com- 
plete anorexia is the rule. On examination, the abdomen is 
often found somewhat distended, tense, and painful, and a 
sausage-like tumor can be made out ; and sometimes upon 
rectal examination the lower border of the intussusception can 
be felt. 

Diagnosis. — The diagnosis depends upon the finding of the 
sausage-like tumor upon palpation, accompanied by tenesmus 
and bloody stools. 

Prognosis. — The prognosis is unfavorable, about 70% of 



500 DISEASES OF THE DIGESTIVE TRACT. 

the cases proving fatal. Spontaneous recovery sometimes 
results from the separation of the invaginated portion of the 
bowel, but in some cases this part may be discharged in small 
fragments. 

Treatment. — The results of surgical treatment are more 
favorable than those of medicinal measures. Opium is neces- 
sary to relieve the pain and to check peristaltic action of the 
intestine, thereby preventing further invagination. Distention 
of the colon by means of warm water slowly introduced may 
prove of value in relieving the invagination. Inflation of the 
intestine by means of air is sometimes practised. If the in- 
vagination be low down in the colon, a rectal bougie carefully 
introduced may relieve the condition. Ice-bags may be applied 
locally to allay pain. Food should be withheld, and ice 
given to relieve thirst. 

HEMORRHOIDS. 

Synonym. — Piles. 

Etiology. — Varicose enlargements of the hemorrhoidal 
plexus of veins are known as hemorrhoids. This condition may 
result from local pressure, frequently from constipation, tumors 
of the rectum, growths from without, enlargements of the 
uterus and ovaries, sometimes from an enlarged prostate, and 
from stricture of the rectum, particularly in syphilitic disease. 
Interference with the portal circulation, especially in atrophic 
cirrhosis, almost constantly causes hemorroids. Diseases of the 
heart and lungs may prevent the return of the venous blood 
and cause stagnation in the hemorrhoidal plexus. Hemor- 
rhoids are commonly met with in middle life. Children rarely 
suffer from piles. Free indulgence in food and lack of exercise 
predispose to hemorrhoids. The affection is also met with in 
gout and obesity, and is more frequently found in men than 
in women. 

Pathology. — Hemorrhoids may be situated above the 
sphincter ani muscle, when they are called internal hemor- 
rhoids. When they are situated below, they are called external 
hemorrhoids. They may be located in either position, and 
frequently in both. When existing externally, they appear as 
irregular links or discs surrounding the anus, are wart-like, 
and of a bluish color. They vary as to size. Internal hemor- 
rhoids are usually broad and flat, and sometimes are pedicu- 
lated, and may protrude through the anus. Inflammation of 
the mucous membranes surrounding the hemorrhoids is almost 



TUMORS OF THE INTESTINES. 501 

always present. Hemorrhoids may undergo ulceration and 
suppuration, and frequently hemorrhage results from them. 
Fistulae may be formed. Thrombosis may occur in these veins. 

Symptoms. — The symptoms vary greatly, depending upon 
the extent. Often they cause great annoyance, accompanied 
by pain of a burning or smarting character, with a sensation 
as if the rectum were occluded by a foreign body. The pain 
is increased during defecation, by horseback-riding, by excessive 
exercise, or by a long-continued, sitting posture. Sometimes 
nausea, vomiting, and palpitation of the heart accompany 
these symptoms. A mucopurulent bloody discharge is fre- 
quently met with as a result of internal hemorrhoids. Some- 
times hemorrhage may be quite profuse. When hemorrhoids 
prolapse and strangulation results, pain is intense. 

Diagnosis. — The diagnosis of hemorrhoids is made by in- 
spection and palpation, the rectal speculum often being of 
value in the diagnosis of internal hemorrhoids. 

Prognosis. — The condition does not prove fatal unless 
accompanied by complications such as septic infection. The 
symptoms usually subside after the removal of the cause. 

Treatment. — Constipation should be relieved and the diet 
carefully regulated. The cause, if possible, should be re- 
moved. It must be remembered that atrophic cirrhosis of the 
liver is usually accompanied by hemorrhoids. Surgical inter- 
ference may prove of value if the condition is purely local, but 
not if arising from obstruction of the portal circulation. The 
affected area should be carefully cleansed, especially after defe- 
cation. Local application of ice is of benefit in relieving pain, 
inflammation, and hemorrhage. Astringents, such as tannic 
acid and nitrate of silver, may be of value in allaying pain. 
An ointment containing carbolic acid, cocain, and belladonna, 
or one of tannic acid or gallic acid and opium, is of great 
value. Hot applications are sometimes most soothing to the 
patient. 

TUMORS OF THE INTESTINES. 

BENIGN TUMORS. 

Of the benign epithelial tumors, adenomata are by far the 
most frequent. They vary greatly in size, and the most com- 
mon situation is in the rectum immediately above the anus ; they 
are found in other parts of the intestines, but are rare. They 
most often appear in children between the ages of four and 



502 DISEASES OF THE DIGESTIVE TRACT. 

seven years (Nothnagel). The surface frequently indicates 
ulceration, and hemorrhage may take place. These tumors 
not infrequently terminate in true carcinoma ; that is, when the 
epithelial cells rupture through the basement membrane. 

Papillomata occur near the end of the rectum and the lower 
part of the ileum. Of the connective-tissue tumors, fibromata 
and lipomata are most frequently found. They may appear 
singly or may be multiple, and vary in size from a pea to a 
large apple. As in papilloma, the most frequent seat is in the 
rectum, and next in frequency in the ileum, and they may also 
appear in other parts of the intestinal tract. 

Myomata and fibromyomata are less common, but have been 
observed in the intestinal tract ; angiomata are exceedingly rare. 

Symptoms. — Symptoms are not characteristic, and unless 
the tumors reach a large size, symptoms may be entirely 
absent. Enterorrhagia occurs, especially with angioma, but 
may also take place with other benign tumors. If enterorrhagia 
take place in the earlier periods of life, tumors of the bowel 
should be suspected. Symptoms of obstruction may also ap- 
pear. Benign tumors can not, as a rule, be palpated through 
the abdominal wall. The tumor may cause death from hem- 
orrhage, obstruction, or invagination. It must always be 
remembered that carcinomatous change may occur in the 
epithelial type. 

Treatment. — The treatment consists in relieving the ob- 
struction, or, if hemorrhage take place, in treating that 
condition. 

MALIGNANT TUMORS. 

Carcinoma. — This is the most common tumor of the intes- 
tines. It is more often found in the male sex, and after the 
fortieth year of life. As to the locality of carcinoma, it is most 
frequently met with in , the rectum, next in frequency in the 
colon. It also occurs in the duodenum, particularly at the 
papilla of the common bile-duct ; it also occurs in the jejunum, 
ileum, and cecum. 

The statistics covering twenty-four years, from 1870 to 1893 
inclusive, from the Pathological Institute of the Allgemeines- 
Krankenhaus in Vienna, collected by Nothnagel, are as follows : 
Out of 41 ,838 autopsies, 343 carcinomata of the intestines were 
found ; affecting the duodenum, 7 cases ; the ileum, 10 ; the 
colon, 164 ; the rectum, 162. The small intestine is much less 
frequently affected than the large. They are nearly always 



TUMORS OF THE INTESTINES. 503 

primary. The most common variety is the adenocarcinoma. 
Its most common seat is in the lower part of the rectum. The 
scirrhous carcinoma is very rarely found in the intestines. 
Encephaloid carcinoma is also found in the intestines. Squa- 
mous cell epithelioma may be met with at the lower end of the 
rectum. 

The cancers of the intestine vary greatly as to size. They 
are commonly found as irregular masses projecting into the 
lumen. Sometimes the cancer encircles the entire lumen. 
They are prone to ulceration, and when this is extensive, per- 
foration and fistulous communications may occur. As a result 
of the ulceration, hemorrhage is not infrequently met with. 
Colloid degeneration may be encountered. These tumors are 
rarely of large size. All the coats of the intestine are usually 
involved. Fistulous communication may be established with 
other parts of the bowel, the stomach,, bladder, vagina, and 
even in some instances through the abdominal wall. The most 
frequent seat of metastasis is in the lymphatic glands and the 
liver. 

Symptoms. — The disease may run its course without char- 
acteristic symptoms, excepting the cachexia and anemia so 
common in malignant diseases. In rapidly growing cancer 
fever commonly occurs ; otherwise the temperature may be 
normal or subnormal. The condition sometimes appears with 
symptoms of occlusion of the bowel, preceded by obstinate 
constipation in the majority of cases. Hemorrhages from the 
bowel are likely to take place. The character of the stools 
varies ; they may be soft, putty-like, scybalous, or ribbon- 
shaped. Pain is a common symptom. It may be local or it 
may radiate. It becomes general when peritoneal involvement 
occurs. It varies in intensity from a dull, unpleasant sensation 
to severe, sharp, colicky pain. Bodily wasting becomes marked 
as the disease progresses. If the situation of the cancer be 
near the opening of the common bile-duct, symptoms of biliary 
obstruction are met with ; jaundice then becomes a prominent 
symptom. The blood reveals a marked decrease in the hemo- 
globin, and a decrease in the erythrocytes, accompanied by 
malignant leukocytosis. 

Physical Examination. — The abdomen is usually scaphoid, 
but when symptoms of obstruction are present, it may be dis- 
tended. In rare instances the tumor may be visible as a pro- 
truding mass, most frequently in the left iliac fossa. Upon 
palpation, a relaxed abdominal wall is met with, and an irreg- 



504 DISEASES OE THE DIGESTIVE TRACT. 

ularly oval or rounded mass, painful upon pressure, is felt. 
If adhesions are not present, the mass is somewhat movable, 
and when metastasis into the lymphatic glands has occurred, 
small nodular masses are sometimes palpable. Sometimes the 
mass can be palpated per rectum and per vaginam. Percus- 
sion gives dullness over the tumor. 

Diagnosis. — The diagnosis of cancer of the intestine depends 
upon the age of the patient, and in many instances upon a 
hereditary tendency, the cancerous cachexia, loss of weight, 
pain, and the detection of the tumor upon palpation. 

Prognosis. — Death from carcinoma of the intestines may 
take place during the course of a few weeks or months or 
not for several years. 

Treatment. — When the diagnosis is made early, surgical 
interference may be of some avail, but usually the condition 
must be treated palliatively. A light, easily assimilated, nu- 
tritious diet should be given. For the pain, opium is indicated. 
Careful attention should be paid to the condition of the bowels ; 
light purgation and enemata are frequently useful. Cannabis 
indica is sometimes of value. When symptoms of obstruction 
are present, lavage and rectal feeding are necessary. 

Sarcoma of the Intestines. — Primary sarcoma of the intes- 
tines is rarely encountered. The disease is usually met with 
in early life, but may occur in middle or advanced periods. 
These tumors spring either from the submucosa or from the 
deeper layer of the intestine. They may give rise to symptoms 
of obstruction. Secondary sarcomata are also found in the 
intestines. 



DISEASES OF THE PERITONEUM. 

ACUTE PERITONITIS. 

Definition. — An acute inflammation of the peritoneum. It 
may be local or general. 

ACUTE GENERAL PERITONITIS. 

Etiology. — The most frequent mode of infection is through 
the intestines and from the female sexual organs. Various 
forms of ulcer may produce peritonitis, such as typhoid, tuber- 
cular, diphtheric, decubital, peptic, syphilitic, and appendicial 



ACUTE PERITONITIS. 505 

inflammation. Malignant diseases may produce acute perito- 
nitis. It also arises from forms of intestinal obstruction, such 
as volvulus and stricture, occasionally from traumatic rupture 
of the intestine, and from impacted feces. Less commonly, 
the inflammation may have its origin in disease of the stomach, 
particularly from gastric ulcer. The gall-bladder and liver 
may be the source of the infection, and particularly abscesses ; 
and syphilitic disease may give rise to it. It may also be of 
carcinomatous or echinococcous origin, or may result from the 
thickening of the interstitial layer from hepatitis. Peritonitis 
rarely occurs from inflammation of the liver. Obstruction of the 
biliary passages by gall-stones may produce .peritonitis. The 
affection may arise from the spleen, through an infected embo- 
lus, or from perisplenitis. Infection from the pancreas is rare. It 
may result from infective, diseases of the kidney. The affection 
may originate from diseases of the bladder-wall, from the pros- 
tate, and the urethra. During the course of erysipelas, espe- 
cially when it involves the skin of the abdomen, peritonitis 
may occur. Peritonitis has been noted during the course of 
acute rheumatic fever and septicemia, rarely during the course 
of scurvy. The disease may be primary or secondary, most 
frequently the latter. There are cases due to bacteria, chemic 
causes, and mechanical causes. 

Peritonitis Due to Bacteria. — Various bacteria may cause 
peritonitis, such as the streptococcus pyogenes, the bacillus coli 
communis, the pneumococcus (diplococcus pneumoniae), the 
staphylococcus pyogenes aureus, bacterium lactis, and, accord- 
ing to Nothnagel, the diplococcus intestinalis major and minor, 
streptococcus conglomeratus, the ray fungus, the bacillus of tet- 
anus, glanders, and diphtheria, the bacillus pyocyaneus and 
streptococcus pyogenes, the proteus vulgaris, the bacillus of 
tuberculosis, the gonococcus, Eberth's bacillus (bacillus ty- 
phosus), and the bacillus of anthrax. Some of these forms of 
micro-organisms may cause primary peritonitis without causing 
inflammation of other structures; most commonly, however, the 
inflammation of the serous coat is secondary to inflammation of 
some surrounding tissue, such as the intestine from ulceration, 
also from inflammation of the pelvic organ's and stomach. The 
three micro-organisms most commonly associated with this in- 
flammation are the streptococcus pyogenes, the bacillus coli 
communis, and the bacillus tuberculosis. Infection may be 
single, when due to one group of micro-organisms ; or mixed, 
when resulting from two or more. 



506 DISEASES OF THE DIGESTIVE TRACT. 

Peritonitis Due to Chemic Irritants.— This may result 
from the bile irritating the serous surface. Toxins produced 
by bacteria in other organs may in many cases produce peri- 
tonitis. When resulting from chemic irritants, the inflamma- 
tion is not of a purulent character, but fibrinous, and rarely 
hemorrhagic. Acute peritonitis may develop during the 
course of acute nephritis and arterial sclerosis. Disinfectants 
when applied to the peritoneum may produce the inflammation. 

Peritonitis Due to Mechanical Causes. — Peritonitis may 
result from blows, or from wounds, such as stab wounds and 
gunshot injuries. When resulting from wounds, bacterial in- 
fection frequently follows. 

Pathology. — Purulent peritonitis is always of bacterial origin. 
Without bacteria, pus does not form in the peritoneum. The 
reverse, however, is not true — that is,. not every peritonitis due 
to bacteria must be purulent or (perhaps more correctly) go 
on to pus formation. 

Chemic peritonitis is serous, serohemorrhagic, or fibrinous. 
The purely mechanical peritonitis is adhesive (fibrinous) only 
(Nothnagel). In opening the abdomen in cases of acute gen- 
eral peritonitis, the visceral and parietal layers will be found 
adherent as a result of the exudation ; indeed, in some cases 
the matting together of the intestines is so marked that it is 
impossible to separate some of the coils of intestine from each 
other. The exudation varies from that of a serofibrinous char- 
acter to fibrinous, fibrinopurulent, purulent, and in some cases 
hemorrhagic. The intestines are found distended in the ma- 
jority of cases. When the exudation is purulent, the pus 
which is found in the peritoneal cavity may be thick and of a 
greenish color. In some instances some fluid or pus may be 
found in the dependent parts of the abdomen, particularly in 
the pelvis. The intestines are injected and often reveal marked 
inflammatory changes, so that the wall becomes very friable. 
They may often be gangrenous. Microscopically, the first 
change noted in acute peritonitis is the swelling and opacity 
of the endothelial cells, the blood-vessels becoming dilated and 
tortuous, and the exudate soon finding its way upon the free 
surface of the peritoneum ; this exudate may be of one of the 
varieties just enumerated, the character depending upon the 
etiologic factor. In acute general peritonitis the disease is usu- 
ally most marked nearest the original focus of inflammation. 

Symptoms. — The symptoms may be ushered in by chilly 
sensations, or a distinct rigor with abdominal pain may mark 



ACUTE PERITONITIS. 507 

the onset. The pain may at first be local, but soon becomes 
general, increased by movement of the patient or by pressure 
upon the abdomen. The position of the patient is frequently 
characteristic. The thighs are partly flexed, so as to relieve 
the tension of the abdominal muscles, and the shoulders are 
elevated. Movements of the patient are restrained, as they 
produce intense pain ; even the pressure of the bedclothes or 
paroxysms of coughing cause distress. Respiratory move- 
ments are restricted to the thorax (thoracic breathing). The 
pulse becomes rapid, small , and hard ; it has been called the 
"wiry pulse." The rapidity of the pulse varies from no to 
160 per minute, or may be even higher. Soon after the onset 
of the disease the temperature rises to 103 F. or io4°F., or 
higher, and continues throughout the attack. Hiccup is a 
distressing symptom, causing severe abdominal pain, and 
frequently precedes the fatal issue. The symptoms are fre- 
quently ushered in by vomiting, which is an important symp- 
tom of the disease. Efforts at vomiting cause intense abdom- 
inal pain. The vomited material is first that of the contents of 
the stomach, later fecal in character, owing to the regurgitation 
of the intestinal contents. Diarrhea may be an early symptom, 
but constipation soon follows ; even flatus rarely escapes, the 
abdomen soon becoming distended, and may be markedly tym- 
panitic. In rare instances the distention is not pronounced. 
Micturition is frequent ; in some instances retention may be 
prominent. The urine is scanty, high-colored, and contains 
an increased amount of indican. % When the disease is well 
advanced, the patient presents a characteristic appearance. 
The vomiting is constant. The expression of the face is anx- 
ious. The features are pinched and the eyes sunken, and 
marked. wasting is apparent. On examination of the abdomen 
distention is noted. On palpation it is rigid, board-like, and 
extremely tender to the touch. Percussion reveals tympany. 
The lower border of liver dullness is obliterated. Splenic 
dullness maybe completely obscured. The heart may also be 
displaced upward. If considerable effusion into the perito- 
neal cavity is present, flatness may be noted upon percussion 
in the flanks. Early in the disease friction sounds may be 
noted on auscultation, but this is rarely found. 

The course of the disease varies greatly, depending upon its 
nature and extent. Death usually results ; it may occur within 
twenty-four or forty-eight hours, or not for eight or ten days. 
As the fatal issue approaches, the surface temperature falls, the 



508 DISEASES OF THE DIGESTIVE TRACT. 

internal temperature, however, being high (pre -agonistic rise); 
the respirations become shallower, the pulse more rapid, 
and occasionally death may result from paralysis of the heart. 

When general peritonitis arises from perforation, symptoms 
of collapse are first present, which come on rapidly, and grad- 
ually the symptoms just enumerated arise. This is an exceed- 
ingly fatal form of peritonitis. 

Diagnosis. — The direct diagnosis depends upon the intense 
pain in the abdomen, which may be continuous, increased upon 
movement or pressure and in urination ; diminished amount 
of urine, with difficulty in voiding ; tympany of the abdomen, 
vomiting, singultus (hiccup), constipation, fever, with small, 
frequent pulse, increased respiration of the thoracic type, the 
characteristic facies, and the symptoms of collapse. These 
symptoms are confirmed by the physical examination in find- 
ing the inflammatory exudate in the peritoneal cavity. 

ACUTE LOCAL PERITONITIS. 

The inflammation may be localized in various parts of the 
peritoneum, the most frequent situations being in the neighbor- 
hood of the appendix and in the pelvis. When in the latter 
position, there is usually inflammation of the sexual apparatus. 
It may involve the diaphragm, when it is called diaphragmatic 
peritonitis. 

Diagnosis. — The diagnosis of this condition can be made 
only when there is an association of pain, exudation, and 
the friction sound in particular localities in the abdomen. The 
diagnosis should never be made from pain alone, as in the 
majority of instances mistakes will arise. 

CHRONIC PERITONITIS (ADHESIVE PERITONITIS). 

Etiology. — This may be local or general. It may result 
from repeated attacks of acute peritonitis, the causes having 
been enumerated in the etiology of the acute form. Occasion- 
ally chronic peritonitis may originate without being preceded 
by acute inflammation. Chronic peritonitis may result from 
tuberculosis or cancer ; it follows trauma and operative proce- 
dures. Local chronic peritonitis is more common than the 
general form. 

Pathology. — On examination of the peritoneum it may be 
found that great thickening is present, and fibrous adhesions 
may be noted. Effusion into the peritoneal cavity is some- 
times observed. 



ACUTE PERITONITIS. 500. 

Symptoms. — The symptoms are not characteristic, and the 
true nature of the affection is revealed only at autopsy in 
many instances. 

Prognosis. — The prognosis of chronic peritonitis is usually 
favorable, but death may result from complications, such as 
intestinal obstruction or pressure upon the abdominal organs. 

Treatment of Peritonitis. — Acute Peritonitis. — Abso- 
lute rest in the recumbent posture is necessary. A pillow 
may be placed under the knees so as to relieve the abdominal 
tension. A cradle may be placed over the abdomen in order 
to support the bedclothes. Food should be withheld while 
vomiting persists, and during this. time rectal feeding is often 
of great value. When vomiting subsides, food should at 
first be given in small amounts, and only in the liquid form. 
Thirst should be relieved by supplying fluids by rectal 
injections. Small pellets of ice may be given the patient 
to relieve the dry condition of the mucous membrane of 
the mouth. After the stomach becomes retentive, water 
should be given in small amounts. Carbonated waters are 
frequently more palatable. Locally, cold is of great value 
in the treatment. A number of ice-bags should be placed 
upon the abdomen, these being retained as long as there 
are any signs of acute inflammation. Turpentine stupes 
may sometimes prove beneficial. In the early stages, when 
vomiting begins, this may be relieved by placing a small fly 
blister in the epigastric region just below the ensiform carti- 
lage. Opium given in liberal amounts is of great value in 
the treatment of peritonitis. Early in the disease, when the 
diagnosis is still in doubt, as peritonitis is so often due to 
causes which necessitate surgical intervention, it is some- 
times advisable to withhold the opium for a short time, as it 
will mask the symptoms ; but if the diagnosis has been 
made, or if diagnosis seems impossible, it is necessary to 
administer opium freely. When vomiting ceases, calomel 
or salines should be administered. Various forms of enemata 
are of great value. Glycerin suppositories, asafetida suppos- 
itories, or the rectal tube may also be employed. Of late, 
operative measures consist in opening the peritoneal cavity, 
with or without drainage, this being recommended by some 
authorities. The operative treatment has been quite suc- 
cessful in suppurative peritonitis, or in the early stages, 
especially when due to intestinal perforation, intestinal ob- 



5IO DISEASES OF THE DIGESTIVE TRACT. 

struction, or appendicitis ; therefore a surgeon should always 
be consulted when dealing with these cases. 

The treatment of chronic peritonitis consists in maintain- 
ing the general health and in the administration of calomel and 
salines. The pain should be relieved by opium ; great care 
must, however, be taken to avoid establishing the opium habit. 
If large effusions are present, they may be relieved by tap- 
ping. In chronic peritonitis the surgeon should be called with- 
out delay. Operative measures often serve to relieve the con- 
dition completely. 

ASCITES. 

Definition. — By ascites is meant an abnormal collection of 
fluid in the peritoneal sac. 

Etiology. — The most frequent cause is obstruction of the 
portal circulation, as occurs particularly in atrophic cirrhosis 
of the liver. This obstruction may also be produced by other 
diseases of the liver, also by tumors or inflammatory masses 
pressing upon the portal vein. It may result from valvular 
heart disease ; ascites, however, occurs late in the course of 
heart disease. Rarely emphysema, chronic pleurisy, and 
interstitial pneumonia may give rise to the condition. Bright's 
disease, and the cachectic states, particularly grave anemias, 
give rise to the condition. The affection may result from 
local disease of the peritoneum, such as cancer and tuber- 
culosis. In rare instances a fatty, milk-like, chylous or 
chylous-like fluid is found in the peritoneal sac, which is 
due to the admixture of fat. Rarely is a chylous ascites 
encountered. 

Symptoms. — The symptoms will depend upon the amount 
of fluid present in the peritoneal cavity, and upon the cause. 
When large quantities of fluid are present in the abdomen, the 
contour of the belly wall is changed ; there is bulging at the 
flanks, and a depressed top. Occasionally, striae may be noted 
upon the skin. The superficial veins are filled. Edema and 
engorgement of the veins of the lower extremities are some- 
times encountered, these symptoms being due to the restricted 
circulation, as a result of the pressure upon the inferior vena 
cava which is produced by the fluid. 

Upon combined palpation and percussion, a wave is elicited. 
This is best performed by tapping the abdomen on one side 
and palpating on the other, and it is well to have an assistant 
place his hand in the median line in a vertical position, so as to 



ASCITES. 5 I I 

avoid a wave being transmitted through the superficial parts. 
Upon percussion a tympanitic note is obtained in the upper 
part of the abdomen, particularly around the umbilicus, when 
the patient is in the recumbent posture, and a flat note will be 
heard in the flanks. On a change of posture the percussion 
note varies ; in the sitting posture tympany will be elicited in 
the epigastrium, and dullness beneath. When there are adhe- 
sions of the intestines, binding these organs together, the 
change in the note does not always occur. It will also be 
noted that the liver, the heart, and the spleen are usually dis- 
placed. 

Differential Diagnosis. — Ovarian Cysts. — Enlargement 
of the abdomen is produced by ovarian cyst, which is often 
enormous. It can be differentiated from the ascites in that 
the shape of the abdomen is different, the enlargement arising 
from the pelvis and extending toward the umbilicus or epi- 
gastrium, the upper portion being somewhat rounded, not 
flattened, as is the case in ascites ; nor does the abdomen sag 
in the flanks in this condition. Fluctuation may be elicited 
upon palpation. Upon percussion, tympany is observed in 
the flanks, and dullness in the upper portion of the abdomen. 
The percussion note does not vary greatly when the posture 
of the patient is changed. 

Prognosis The prognosis depends upon the cause. As a 

rule, it is unfavorable. 

Treatment. — The treatment should at first be directed to 
the cause. When the fluid becomes excessive, tapping is 
necessary {paracentesis abdominis}. 

For the purpose of tapping, a trocar and a cannula are used. 
In performing this operation, care must always be taken that 
the bladder be thoroughly emptied. The point of selection 
is in the median line, midway between the umbilicus and the 
symphysis pubis. A many -tailed bandage may be used, trac- 
tion being made upon the ends as the fluid flows through the 
trocar. The patient should be in the sitting posture. All the 
fluid may be withdrawn unless symptoms of collapse mani- 
fest themselves, when the operation must be suspended at 
once. When fluid reforms, which it does very rapidly in the 
majority of instances, another tapping is necessary. Occa- 
sionally the rapid formation of the fluid may be somewhat de- 
layed by a tight bandage over the abdomen. 



512 DISEASES OF THE DIGESTIVE TRACT. 



TUMORS OF THE PERITONEUM. 

BENIGN TUMORS. 

Fibromata are occasionally met with ; they rarely attain 
great size, and seldom give rise to symptoms. Lipoma and 
fibrolipoma may attain enormous size. In a case recorded by 
Waldeyer, the weight of the growth was 3 1 J^ kilograms. These 
tumors may be single or multiple, and are most frequently 
found in persons between the ages of thirty and fifty. An- 
giomata are sometimes encountered. Myoma and fibro- 
myoma have been encountered, but they are of rare occurence. 

Symptoms. — The symptoms are due to the pressure pro- 
duced by these tumors. 

MALIGNANT TUMORS. 

Sarcoma of the Peritoneum. — In this group are included 
those growths which spring from the peritoneal or the subperi- 
toneal tissue, the most common situations being in the connec- 
tive tissue behind the peritoneum, in the greater omentum, and 
in the folds of the broad ligament or upon the surface of the 
liver. The retroperitoneal lymphatic glands are also some- 
times the site of origin. 

Sarcomata of the peritoneum may be primary or secondary. 
When it is secondary, the primary seat frequently is in the 
testes or ovary, or sometimes in the kidney. They are found 
more commonly in males than in females, in adult life, some- 
times at an early age, and there may be a history of trauma. 

The varieties of sarcomata met with are the round-cell, 
spindle-cell, lymphosarcoma, and mixed-cell. They may be 
combined with fibromata, and in some instances reveal exten- 
sive myxomatous degeneration, and often melanotic pigmen- 
tation. 

These tumors may be single or multiple, and attain an enor- 
mous weight — thirty pounds or more. Like all sarcomata, 
they are usually very vascular. They may be soft or hard, 
depending upon the fibrous elements which are so frequently 
combined. 

Chronic inflammatory changes of the peritoneum are fre- 
quently associated. Interference with the normal lymphatic 
transudates in the peritoneum is sometimes noted, giving rise 
to ascites. From the pressure of these tumors or from the 
pressure of the ascites upon the vena cava, edema of the lower 



TUMORS OF THE PERITONEUM. 513 

limbs may be encountered. Interference with the portal cir- 
culation gives rise to distention of the superficial veins (col- 
lateral circulation). 

Symptoms. — The symptoms greatly depend upon the size 
and situation of the tumor, also upon the fact whether it be 
primary or secondary. The patient often complains of vague 
abdominal pain, and sometimes of nausea, vomiting, and 
loss of appetite-; there are loss of weight, failing strength, 
and general ill health. 

Upon examination, the zvasting and anemia are usually dis- 
tinctive signs. Examination of the abdomen will usually 
reveal the true nature of the condition. If it be a sarcoma of 
the omentum, upon palpation a hard, irregular, flattened mass, 
tender upon pressure, will be noted. The tumor is freely 
movable from side to side, and light percussion will elicit a 
dull note. If the tumor be situated in the mesentery, it is 
usually palpable above or below the umbilicus, in the median 
line, is freely movable unless adhesions have taken place, and 
its shape is commonly globular. If the sarcoma be situated 
behind the peritoneum, and is of considerable size, it displaces 
many of the abdominal viscera, such as the pancreas, the in- 
testines, and the kidneys. 

Prognosis. — The course of these tumors is usually brief — a 
few months or a year, the prognosis in all instances being in- 
variably grave. 

Carcinoma of the Peritoneum. — Whether primary carci- 
noma of the peritoneum ever exists is doubted by some 
observers, and it seems probable that many of these tumors 
that have been described really belong to the class of alveolar 
sarcomata. The pathologic distinction between alveolar sar- 
coma and carcinoma is extremely difficult, and in some cases 
impossible. 

Secondary carcinomata of the peritoneum are not infrequent, 
the primary seat commonly being the ovary, or less often the 
gall-bladder, pancreas, liver, stomach, intestines, esophagus, 
and breast. They are probably more common in women, 
occurring in middle or more advanced life, and occasionally 
in the young. When the peritoneum is involved secondarily, 
there will be observed a great number of nodules, the size of 
which varies from that of a pinhead to a pea or marble ; they 
are often clustered. These miliary or multiple forms may be 
of a primary or secondary nature. 

The tumor may be of comparatively large size, be quite 
33 



514 DISEASES OF THE DIGESTIVE TRACT. 

hard, and give the characteristics of scirrhous carcinoma. 
Occasionally large tumors which have undergone colloid de- 
generation have been recorded. There is often some degree- 
of ascites, particularly when the carcinoma is multiple. The 
fluid contained in the peritoneal cavity may be serous, occa- 
sionally hemorrhagic, and rarely chylous. 

Symptoms. — The onset is very insidious, the patient com- 
plaining of loss of strength, loss of appetite, and loss of weight. 
Anemia and cachexia develop. The symptoms are much in- 
fluenced by the position of the tumor and its primary seat. 
Abdominal pain may be colicky in character, and is a very fre- 
quent symptom ; however, it does not occur in all cases. The 
temperature is usually subnormal. Constipation is the rule, 
but attacks of diarrhea often alternate, and vomiting may also 
occur. The loss of weight is, in some cases, enormous. 

Upon examination of the abdomen, the physical signs of 
ascites, the palpation of the nodular mass, and pain upon pres- 
sure frequently reveal the true nature of the condition. When 
the tumors are large, they are usually movable, but late in 
their course they become bound down by adhesions. 

Prognosis. — The disease is of short duration, rarely lasting 
longer than six months, and invariably terminating fatally. 

Treatment of Malignant Tumors of the Peritoneum. — 
If the diagnosis be made early, while the tumor is small, opera- 
tive measures may be of value. As a rule, however, complete 
removal is impossible. If ascites be pronounced, paracentesis 
abdominis may be performed. The diet should be nutritious 
and easily assimilable. The bowels should be regulated, and 
pain must be relieved by the administration of opium. 

CYSTS OF THE PERITONEUM. 

The peritoneal and subperitoneal tissue may be the seat of 
hydatid cysts, these frequently being multiple, also dermoid 
cysts, and rarely chylous cysts. 

The signs and symptoms depend upon the location and the 
size of the cyst. Their duration is variable, and when they 
are of only moderate size they are frequently not detected 
until the autopsy is made. If the cyst be situated so as to 
cause some degree of intestinal obstruction, the symptoms 
relating to obstruction will occur ; if situated in relation to the 
common bile-duct, symptoms of jaundice will arise. The 
diagnosis is difficult in many instances. 



ACTIVE CONGESTION OF THE LIVER. 5 I 5 



DISEASES OF THE LIVER. 

DISPLACEMENTS OF THE LIVER. 

Displacements of the liver may be due to pressure from above 
the diaphragm, such as thoracic tumors, pleurisy with effusion, 
and effusion into the pericardium ; to tumors or abscesses be- 
tween the liver and the diaphragm ; or to a relaxation of the 
hepatic ligaments. Of the latter, the most important causes 
are pregnancy at full term, a pendulous abdomen, stretching 
of the ligaments, and a tearing or twisting of the suspensory 
ligament. Tight lacing produces a change in the form of the 
liver rather than in its position, but both conditions may occur 
in the same case. 

Symptoms. — A sudden onset is rare ; when this occurs, 
there is pain in the hepatic region, with irregular, rapid 
pulse, a feeling of weight, and severe dyspeptic symptoms. 
There may be jaundice. In the greater number of cases the 
onset is gradual. The physical signs show the presence of 
a tumor in the abdomen, with the shape, size, and consistency 
of the liver. A point of importance in the diagnosis consists 
in the difficulty of replacing the liver in its normal position. 
If the liver be greatly displaced, a tympanitic resonance instead 
of flatness occurs in the normal hepatic area. 

Diagnosis. — Floating liver may be mistaken for ovarian 
cyst, movable right kidney with hydronephrosis, and malig- 
nant disease of the omentum. Important points in the diag- 
nosis are the upper smooth surface, with the sharply defined 
anterior border and notch, the tympanitic resonance over the 
hepatic region where normally liver flatness should exist, and 
the ability to partially or completely restore the displaced 
liver to its normal position. 

Treatment. — Support of the abdominal walls to hold the 
liver in its normal position should be tried. Surgical treat- 
ment has been successful in several instances. 



ACTIVE CONGESTION OF THE LIVER* 

Definition. — An increased amount of blood in the liver 
due to an increase in the flow of blood through the organ. 
Synonyms. — Hyperemia ; active hyperemia. 



5 16 DISEASES OF THE DIGESTIVE TRACT. 

Etiology. — The condition is physiologic during digestion. 
It occurs during active exercise, and. results from overeating, 
overindulgence in malt liquors, wines, etc., and from the in- 
gestion of highly seasoned foods. It results from malaria, 
dysentery, yellow fever, Weil's disease, and enteric fever. 
Cold is regarded as an etiologic factor. It occurs during the 
course of diabetes mellitus, and sometimes from suppressed 
menstruation. 

Pathology. — The pathologic changes on the postmortem 
table are not constant, and are often ill defined. The liver may 
be enlarged and of a dark red color, and on section blood drips 
from the cut surface. On viewing the cut surface it may be 
slightly mottled ; this, however, is never so pronounced as in 
passive congestion (the " nutmeg " liver), in the latter condi- 
tion it being due to the distention of the intralobular veins. 
On microscopic examination cloudy swelling sometimes ac- 
companies hyperemia. 

Symptoms. — The symptoms are those of gastro-intestinal 
catarrh, such as constipation, loss of, or perverted appetite, 
coated tongue, and headache. The complexion of the patient 
is often muddy. There may be slight pain or a sense of dis- 
comfort in the region of the liver, and some tenderness on 
pressure. Slight jaundice sometimes arises ; rarely is this in- 
tense. Mental depression, irritability, headache, and dizziness 
are often prominent symptoms. 

Upon examination, the liver may be found slightly enlarged, 
but this is difficult to determine. 

Prognosis. — The disease frequently terminates in more 
serious affections of the liver, it being in itself not danger- 
ous. 

Treatment. — Errors in diet must be corrected, and the 
food should be light, nutritious, and easily assimilable. Highly 
seasoned foods must be avoided. In many instances a milk 
diet may be instituted. Alcohol must be avoided. System- 
atic purgation is necessary. It is best to administer Carlsbad 
salts, Rochelle salts, and calomel. Pills of aloin, belladonna, 
and strychnin are frequently of use. Benefit may be derived, 
from a visit to some watering-place, such as Carlsbad, Hom- 
burg, etc. 



PASSIVE CONGESTION OF THE LIVER. 517 

PASSIVE CONGESTION OF THE LIVER. 

Definition. — A condition characterized by enlargement 
of the liver, and due to an interference with the outflowing 
blood from the organ, the cause in nearly all instances being 
heart disease. 

Synonyms. — Passive hyperemia; congestion; nutmeg liver; 
cyanotic liver ; red atrophy of the liver ; liver of heart disease. 

Etiology. — This depends upon the interference of the out- 
flowing blood from the hepatic veins, so that the liver contains a 
greater amount of venous blood than normal. As before stated, 
in nearly all instances it is due to a cardiac lesion, particularly 
when the right heart fails to do its work, and the blood dams 
back into the inferior vena cava and the hepatic veins. The 
blood may be retarded as a result of pulmonary disease, such as 
chronic interstitial pneumonia, compression of the lung (atelec- 
tasis), pleural effusions, intrathoracic tumors, and aneurysms. 
In rare instances it may be due to pressure upon the hepatic 
veins or upon the inferior vena cava, causing a constriction. 

Pathology. — The organ is enlarged, but this enlargement 
is never so great at the autopsy as it is antemortem, the blood 
tending to leak out of the organ after death. The surface is 
smooth and the edges are rounded, and it is of a bluish-black 
color. On section the knife meets with more resistance than 
normally, as a rule. The cut surface appears mottled, and 
drips blood. Upon microscopic examination it will be found 
that the intralobular veins are greatly distended with blood 
and dilated. As a result of this, many of the liver-cells sur- 
rounding these veins are atrophied, large numbers having dis- 
appeared. Yellowish-brown pigment is deposited in many of 
the surrounding liver-cells. Fatty infiltration is also observed 
in the portal vein zone — this being due to the slowing of the 
circulation. The mottled appearance is due to the engorged 
intralobular veins, the color being blue or black, and to the 
contrasting light color of the surrounding liver-cells, many 
being infiltrated with fat. If the condition be of long standing, 
fibrous connective-tissue formation is often noticed around the 
intralobular veins. Secondarily, the portal circulation may be 
disturbed, giving rise to enlargement of the vein and to ascites. 

Symptoms. — These depend more upon the primary condi- 
tion than those produced by the enlargement of the liver, the 
patient often complaining of a sensation of tension or pain in 
the right hypochondriac region. 



5 18 DISEASES OF THE DIGESTIVE TRACT. 

Upon palpation, pulsation is sometimes noted, the liver also 
being found enlarged and tender to the touch. The gastro- 
intestinal symptoms depend upon the degree of portal conges- 
tion. Slight jaundice and the occurrence of ascites are also 
encountered. 

Prognosis. — The prognosis depends entirely upon the 
cause of the congestion. 

Treatment. — The treatment must be directed toward the 
cause ; and if due to valvular heart disease, the use of digitalis 
frequently relieves the condition. Calomel and Rochelle and 
Carlsbad salts are of value in the treatment. If the local 
symptoms are severe, the application of leeches or blisters 
may be of some use. 

FATTY LIVER. 

Synonym. — Steatosis of the liver. 

Etiology. — The distinction between fatty infiltration and 
fatty degeneration of the liver is by no means clear, and as 
yet too little is known of the changes that take place in fatty 
degeneration, or the reason of fat production in the liver cells. 
The normal amount of fat in the liver fluctuates ; it is com- 
monly between 3^ and 5^. In fatty liver as much as 40^ 
and over has been found. This condition may be physiologic, 
occurring after a full meal, particularly after partaking of food 
consisting largely of carbohydrates. It is physiologic in in- 
fants, being due to the milk diet. It results from the par- 
taking of large quantities of carbonaceous food ; from de- 
ficient oxidation, this being met with in tuberculosis of the 
lungs and certain of the anemias, as pernicious anemia and 
chlorosis. It arises from the excessive use of alcohol, from 
insufficient exercise, and from the slowing of the blood through 
the liver, as occurs at the onset of atrophic cirrhosis, or from 
passive congestion ; and, finally, it occurs as a hereditary con- 
dition, obesity being common in many families. It may be 
due to poisoning, particularly by phosphorus ; or it may 
result from poisoning by arsenic, antimonium, copper, mer- 
cury, and aluminium salts. It may also be due to the min- 
eral acids, such as nitric, hydrochloric, and sulphuric acids. 
It has been observed after toxic doses of carbon dioxid, 
chloroform, iodoform, and carbolic acid, from the contin- 
ued use of morphin, from poisonous mushrooms, and from 
the ptomains of flesh, fish, and mussels. It has been noted 



FATTY LIVER. 519 

after partaking of poisoned maize, as in pellagra. It occurs 
as a result of some of the infectious diseases, particularly 
yellow fever, puerperal fever, osteomyelitis, and erysipelas, 
and in conditions in which long-continued pus formation oc- 
curs. It has been noted after variola, severe diphtheria, and 
scarlet fever, and occasionally after typhus, cholera, and 
pneumonia. It rarely takes place in the course of chronic 
dysentery, and may occur in rachitic children. 

Pathology. — In well-marked "fatty infiltration the organ is 
increased in size, the surface is smooth, and the edges are some- 
what rounded. The total weight is increased, but the specific 
gravity is decreased. The color is of a lighter shade than 
normal, being yellowish. On section, the knife meets with 
little resistance, and fat globules may appear upon the knife, 
the cut surface being of a yellowish-red color, and frequently 
mottled, there being areas of a light yellow color intermingled 
with those of a reddish shade. Sometimes large portions of 
the organ are of a light yellow color. Upon microscopic 
examination it will be found that the outer zone of the liver 
lobule particularly is invaded with fat ; many of the liver-cells 
are very large, being distended with fat, and the nucleus being 
pushed to one side. If the infiltration be pronounced, other 
portions of the liver lobule will be involved. Pathologically, 
it is sometimes difficult or impossible to distinguish fatty infil- 
tration from fatty degeneration. In well-defined cases of fatty 
degeneration the size of the organ is decreased ; it is very fri- 
able, soft, and sometimes semifluid, and fluctuating. It is of 
a deep yellowish-red color, and upon microscopic examination 
it will be found that many of the liver-cells are filled with 
small globules of fat, others revealing parenchymatous degen- 
eration. 

Symptoms. — Upon palpation the liver is noted to be soft, 
and the inferior margin is found lower in the abdomen than 
normally. Upon percussion, it is observed that the organ 
is considerably enlarged. ^The surface seems smooth, the 
margin rounded, and the general outline of the liver re- 
mains the same as normal. Ascites and enlargement of the 
spleen are rare ; if present, they are due to some complica- 
tion. Gastro-intestinal disturbances are common ; there is 
loss of appetite, flatulency, and constipation alternating with 
diarrhea, the stools containing mucus. Meteorism is common. 
Hemorrhages are frequently noted. Jaundice is rare. The 
bile is diminished in amount due to the decreased activity of 



520 DISEASES OF THE DIGESTIVE TRACT. 

the liver-cells. Upon examination of the urine, it will be noted 
that urobilin is excreted in diminished amounts. The appear- 
ance of the patient and the general symptoms depend largely 
upon the cause. 

Course and Duration. — The disease runs a chronic course, 
being much influenced by complications, which are frequently 
present, such as fatty heart and fatty kidney. 

Treatment. — If possible, efforts should be made to remove 
the cause. If this be obesity, fatty and saccharine food should 
be eliminated from the diet, and albuminoid substances substi- 
tuted. Meat, fish, green vegetables, and plain broths may be 
given. All stimulants should be avoided, especially beer and 
sweet wines. Systematic exercise should be insisted upon. 
The alkaline waters, Carlsbad, Vichy, and Kissingen, are bene- 
ficial. If there be anemia, iron and arsenic are of use. 



AMYLOID DISEASE OF THE LIVER. 

This" is part of a general process, in which the spleen, 
kidneys, and intestines are also frequently involved. Occa- 
sionally it results from hereditary or acquired syphilis. The 
disease may be congenital, and is found at all ages from 
two to seventy years, occurring most frequently between the 
ages of twenty and thirty. It is more frequently found in men 
than in women. The disease is often due to suppurative pro- 
cesses, especially those affecting bone, also chronic malaria 
and tuberculosis. 

Pathology. — The organ is greatly increased in size and 
weight. The surface is quite smooth and the edges are 
rounded. The specific gravity is increased. The color of the 
organ is a pale yellow. On section the knife meets, with much 
resistance. The organ is tough, elastic, and pits but slightly 
upon pressure. 

Test for Amyloid Material. — \Vhen a small section of the 
liver is treated with a weak iodin solution (or Lugol's solution), 
the amyloid material will stain a mahogany brown, and the 
remaining liver substance a light yellow. The test is also well 
demonstrated with some of the anilin dyes, such as gentian- 
violet, a rose-red color being developed when a solution of 
this kind is applied. Similar stains, such as methyl-green and 
methyl-violet, give like reactions. 

Microscopic examination will reveal the amyloid material 



ATROPHIC CIRRHOSIS OF THE LIVER. 52 1 

infiltrated into the liver lobule. Early in the disease the 
hepatic artery or middle zone is first involved ; later in the 
course of the affection the cells in the inner and outer zones 
are also involved. The smaller arteries also reveal amyloid 
material in their coats. 

Symptoms. — The liver is found enlarged if there be an ex- 
tensive deposit of amyloid material ; occasionally it is found 
smaller than normal, the surface being smooth and firm, and 
the lower margin rounded and distinctly palpable. Pain is 
present if perihepatitis occurs. Ascites is rare. Enlargement 
of the spleen results in more than one-half of the cases. 
Unless some complication occurs, such as an enlargement of 
the lymphatic glands in the portal fissure, jaundice is absent. 
Dyspeptic symptoms are common ; there is anorexia, nausea, 
and vomiting. Diarrhea, and anemia with leukocytosis, are 
common symptoms. The appearance of the face is character- 
istic ; there is sallowness with pallor, the patient suffering 
from more or less debility. If edema be present, it is most 
likely due to a similar change in the kidneys. 

Course and Duration. — The disease often extends over 
many months ; the course, however, is progressive, death re- 
sulting from anemia, kidney complication, or some intercurrent 
affection, as pneumonia or dysentery. 

The prognosis is always unfavorable. If the disease be due 
to suppurative processes, these will require careful attention. 

Treatment. — The general hygiene of the patient should be 
carefully looked after. The diet should consist of nutritious 
food, containing very little fatty, farinaceous, or saccharine 
material. If the disease be of syphilitic origin, iodid of potas- 
sium and mercury are of use. 

ATROPHIC CIRRHOSIS OF THE LIVER. 

Synonyms. — Chronic interstitial hepatitis ; hobnail liver ; 
gin-drinker's liver ; finely granular liver ; Laennec's cirrhosis. 

Etiology. — The disease occurs particularly in the male 
sex, and is often due to alcohol. In the new-born the disease 
is due to hereditary syphilis. The second most important 
cause is acquired syphilis, malaria, and other infectious diseases, 
as cholera, enteric fever, and scarlet fever. Gout and rickets 
particularly give rise to this condition. The disease has been 
known to follow miliary tuberculosis. It also arises in the 
course of perihepatitis. It may accompany red atrophy of 



522 DISEASES OF THE DIGESTIVE TRACT. 

the liver. The individual predisposition is of some impor- 
tance as an etiologic factor. Occasionally the disease oc- 
curs without assignable cause. 

Pathology. — The liver is commonly greatly diminished in 
size and in weight, but the specific gravity is increased. The 
surface is irregular, being lobulated or finely granular ; the 
edges, also, are nodulated. On palpation it is found to be 
extremely tough — india-rubber-like. On section, the knife 
meets with much more resistance than the normal organ. 
The color is lighter than normal, being yellowish-red, or in 
some instances a light red. Some of the lighter areas indi- 
cate bands of fibrous connective tissue which traverse the organ. 

Microscopic examination reveals a great increase in the 
connective tissue, which is especially well marked around the 
lobules and interlobular vessels. As a result of the contrac- 
tion of this new cicatricial tissue, many of the liver-cells disap- 
pear from pressure atrophy, and the finer blood-vessels are 
pressed upon. 

The radicles of the portal vein, because of their weak walls 
and of the low blood pressure in the vessels, seem to suffer 
more than the accompanying vessels. For this reason portal 
obstruction results. The cicatricial bands are found travers- 
ing the liver, many of the lobules being distinctly defined. 
Large numbers of these bands reach to the surface, and, on 
account of the secondary contraction, produce a distortion in 
the outline of the liver (hobnail liver). The portal obstruction 
leads to congestion of the spleen, this organ becoming large 
and of a dark red color. It also leads to congestion of the 
stomach, the small intestines, and the large intestine, this 
being especially marked in the rectum. The hemorrhoidal 
plexus of veins becomes distended, tortuous, and elongated, 
giving rise to hemorrhoids. The portal congestion causes 
transudation of the serum into the peritoneal cavity, and ascites 
results. Collateral circulation, that connecting the portal with 
the general venous system, is in most instances established, 
so that the superficial abdominal veins become greatly dis- 
tended. The left ventricle of the heart may show slight 
hypertrophy. In the early stages of cirrhosis the liver usu- 
ally presents slight enlargement and some degree of fatty infil- 
tration, the latter probably resulting from slowing of the cir- 
culation. Very late in atrophic cirrhosis of the liver the con- 
traction of the connective tissue may be extreme, giving rise 
to narrowing of the biliary ducts. 



ATROPHIC CIRRHOSIS OF THE LIVER. 523 

Symptoms. — The prodromal stage may occur without giv- 
ing rise to symptoms, except in the case of topers in whom 
there is a long preceding history of gastro-intestinal catarrh. 
There are symptoms of anorexia, sensations of pressure in the 
epigastrium, constipation alternating with diarrhea, early morn- 
ing nausea and vomiting, and so on. Early in the course of 
the affection some slight enlargement of the liver may some- 
times be made out by the methods of physical diagnosis. 
When the disease has established itself, the organ becomes 
distinctly diminished in size. Occasionally the diminution in 
the size of the liver is very difficult to determine, owing to the 
fact that shrinkage occurs in the diaphragmatic portion of the 
liver. Of decided diagnostic import is an early atrophic 
change in the left lobe of the liver, which in some cases can 
scarcely be felt in the abdominal cavity. If perihepatitis 
occur, distinct fremitus may be elicited -in some cases upon 
palpation. Jaundice, as a rule, is absent ; and if present, it is 
slight in amount, occurring only late in the course of the affec- 
tion. The symptoms depend upon the disturbance in the cir- 
culation of the blood in the portal vein, or upon the diminished 
function in the atrophied cells of the liver, or upon a combina- 
tion of these two affections. The most characteristic symptoms 
are those relating to disturbance of the circulation in the portal 
vein. The result of this is a marked ascites. Even before 
this the effect of congestion of the mucous membranes of the 
stomach and bowels may be noted by hematemesis and enter- 
orrhagia, which occur in the course of this affection. With 
this there may be constipation, alternating with diarrhea ; and 
meteorism is often a prominent symptom. Soon hemorrhoids 
begin to show themselves, as a result of the overfilled portal 
circulation. The spleen is enlarged. The ascites is often 
pronounced, and may be so great as to push the diaphragm 
so far upward as to compress the lungs and heart, giving rise 
to dyspnea, and often orthopnea. The pulse is irregular and 
intermittent, from the disturbance of the heart. 

From the pressure occasioned by a large effusion, interfer- 
ence with the venous return in the inferior vena cava is pro- 
duced, this giving rise to edema of the lower extremities. The 
cutaneous veins of the abdomen are often greatly enlarged ; 
this frequently shows itself around and in the neighborhood 
of the umbilicus, giving rise to the so-called " caput medusae." 
The urine is diminished in amount, of low specific gravity, and 
reddish in color. If albuminuria occur, it is due to a complicat- 



524 DISEASES OF THE DIGESTIVE TRACT. 

ing urinary affection, the same sclerotic process very often going 
on in the kidney. The red color of the urine is due to the 
urobilin, which is often excreted in increased amounts. Urea, 
as a rule, is diminished. Occasionally, traces of sugar may 
be found. The occurrence of sugar in the urine of persons 
suffering from atrophic cirrhosis may be explained by a dis- 
turbed metabolism in the organ. Occasionally leucin and 
ty rosin have been found (?). 

The temperature, as a rule, is normal or subnormal, sub- 
febrile or febrile ranges being due to complications. The 
general nutrition suffers greatly. The patient becomes thin, 
the muscle tonus is lost or diminished, and there is marked 
anemia. In - some cases cerebral symptoms occur, with 
delirium, stupor, and coma. Rarely convulsions occur. 
These are said not to be due to uremia or clwlcmia. 

Complications. — The most common complications are in- 
terstitial and parenchymatous nephritis. Myocarditis also 
occurs. Complications which relate to the liver are found in 
fatty infiltration and passive congestion. Abscesses, amyloid 
disease, and carcinoma occasionally develop in the cirrhotic 
liver. Sometimes large hemorrhages may occur from the 
lungs, from the urinary passages, and from the nose (epistaxis). 
Hemorrhages from the stomach and bowels have already been 
mentioned among the symptoms ; these may be profuse, and 
are the most frequent forms of hemorrhage. Epistaxis has 
occasionally led to the fatal issue. 

Prognosis. — The course of the disease is prolonged, much 
depending upon the compensatory collateral circulation, the 
duration in many cases being ten years or more ; however, 
always terminating fatally. The cases due to malaria and 
syphilis are more favorable if the condition be diagnosticated 
early. 

Treatment. — The treatment consists in abstaining from 
alcohol, avoiding rich foods, and leading a quiet life. The 
bowels should be carefully regulated, and the skin kept in a 
good condition by frequent bathing. Iodid of potassium and 
mercury are of use only in the syphilitic forms of the disease. 
When the disease is well advanced, the bowels should be kept 
freely open by the use of calomel, salines, compound jalap 
powder, elaterium, etc. When the ascites is pronounced and 
pressure develops, paracentesis abdominis becomes necessary. 
The double chlorid of gold and sodium is recommended in 
the beginning of the disease. 



BILIARY AND CONGESTION CIRRHOSIS. 525 

BILIARY CIRRHOSIS. 

Definition. — Cirrhosis due to obstruction of the gall-ducts, 
bile being retained in the liver. 

The French school of physicians differentiated two forms 
of cirrhosis — a hypertrophied biliary cirrhosis (Hanot), due to 
disease of the small biliary passages, and a biliary cirrhosis 
due to obstruction, with sclerotic change in and around the 
larger gall-ducts, producing thickening of these ducts. 

Pathology. — The organ is large and tough, and upon sec- 
tion presents a reddish-yellow color, sometimes "nutmeg" in 
appearance, this being due to the yellow discoloration of the 
central part of the liver lobule surrounded by the red per- 
iphery. The surface of the organ is quite smooth, and rarely 
becomes granular. The biliary ducts are dilated, and present 
sclerotic thickening around them. The gall-bladder may also 
reveal thickening and some catarrhal" inflammation. This 
change may also exist in the large ducts. The newly formed 
connective tissue which exists around the lobules may push 
its way into the lobules. 

Symptoms. — Jaundice coming on rapidly, with perhaps the 
symptoms of hepatic colic, is often characteristic. The jaun- 
dice in some cases may disappear after the passage of the 
stone. If the liver remains enlarged, there is great similarity 
between this and the ordinary form of cirrhosis ; however, in 
this disease the jaundice is more marked, and ascites occurs. 

Treatment. — The treatment is expectant symptomatic. 

CONGESTION CIRRHOSIS. 

In the majority of cases red atrophy is not accompanied 
by marked cirrhotic change, but in a few instances in which 
congestion is long continued new-formed fibrous connective 
tissue develops, giving rise to cirrhosis. The organ will 
be found hard, and the surface slightly granular. The cap- 
sule is wrinkled, and the organ is reduced in size. On sec- 
tion it presents the characteristic appearance of red atrophy, 
showing the dark red central zone of the lobule and the lighter 
peripheral portion. Upon- microscopic examination the char- 
acteristics of red atrophy with new-formed connective tissue 
are observed. 

Symptoms. — The symptoms are those of atrophic cirrhosis, 
usually complicated by valvular heart disease. 



526 DISEASES OF THE DIGESTIVE TRACT. 



CIRRHOSIS DUE TO MALARIA. 

This form of cirrhosis is rare. Osier says that in a large 
number of malarial cases observed in the Johns Hopkins 
Hospital during the last nine years not a single case of 
cirrhosis complicating this disease was noted. It is said that 
the melanin which lodges in the liver produces the chronic 
inflammation, fibrous connective tissue developing in large 
amounts. Jaundice accompanies the cirrhotic condition. 
Iron pigmentation is noticed in the liver-cells nearest the 
central and peripheral zones. In this form of cirrhosis 
there are pain upon pressure, vomiting of bile, and biliary 
diarrhea, which is often due to biliary pigments and hemo- 
globin. This occurs particularly in the black water fevers, and 
in other forms of tropical malaria. This form of cirrhosis is 
particularly well marked in malarial cachexia, the liver being 
extremely large, weighing from 2000 to 3000 grams, revealing 
perihepatitis and marked pigmentation. 

. SYPHILITIC CIRRHOSIS. 

This may be due either to congenital or acquired syphilis. 
The liver becomes enlarged, tough, and resistant, being as 
hard as sole-leather, in a measure resembling amyloid liver. 

Upon microscopic examination it will be observed that 
there is a great increase in the connective tissue between the 
lobules, many areas revealing numerous round and spindle cells. 
Gummata may also be found in this condition. These may 
vary from the size of a millet-seed to that of a walnut, and 
sometimes even larger. These gummata vary from a reddish - 
green to a creamy white color. They are often surrounded by 
a zone of fibrous connective tissue, and when contraction of 
this newly formed tissue occurs, marked distortion of the 
organ results. The gummata may occur in the liver without 
extensive cirrhosis during the course of acquired or congenital 
syphilis. 

Symptoms. — The symptoms are those of atrophic cir- 
rhosis — ascites, loss of weight, gastric derangements, anemia, 
and, late in the course, slight jaundice. 

Diagnosis. — The diagnosis depends upon the history of 
infection, with enlargement of the organ. 

Treatment. — Antisyphilitic treatment should be instituted 
early. 



HYPERTROPHIC CIRRHOSIS. 527 



HYPERTROPHIC CIRRHOSIS- 

Synonyms. — Hanot's cirrhosis ; biliary cirrhosis ; enlarged 
cirrhotic liver. 

Etiology. — This is a comparatively rare affection, occurring 
in the male sex, most frequently between the ages of twenty 
and thirty-five. Very little is known about the etiology. It 
has been said that- malaria, syphilis, enteric fever, and cholera 
are predisposing factors. Alcohol has also been mentioned as 
a predisposing factor. The disease appears to be much more 
frequent in France than in other parts of the world. Lately 
the hypothesis has been advocated" that it is due to a primary 
parasitic disease of the biliary passages. It is possible that 
protozoa and bacteria may have some share in the process. 

Pathology. — The organ is greatly increased in size, in some 
instances weighing as much as 4000 grams. The surface is 
granular. The portion of the peritoneal coat which lines the 
liver is frequently adherent to the organ, and is thickened. The 
liver is tough, cuts with much resistance, and is bile-stained, 
giving the organ a yellowish-green color. Microscopic exam- 
ination reveals large masses of fibrous connective tissue between 
the lobules, and it is said that this connective tissue does not 
show the marked tendency to contraction that is so charac- 
teristic of the atrophic form. Aufrecht called attention to the 
fact that all the liver-cells are enlarged, and contain more than 
one nucleus. In the interlobular portions of the organ large 
numbers of round cells are frequently noted, as well as a 
number of fibroblasts and some fully developed connective 
tissue. The biliary passages show catarrhal change, and 
there is also a great increase in the number of ducts. The 
spleen is greatly enlarged, and the various tissues of the 
body are usually deeply bile-stained. Leukocytosis may be 
present. 

Symptoms. — The early symptoms of the disease are not 
characteristic. They may consist of irregular gastric phe- 
nomena, such as nausea, loss of appetite, and a sensation 
of pressure in the epigastrium. It is only when the liver 
enlarges and becomes painful, and jaundice develops, that 
the symptoms of the disease become characteristic. At the 
height of the affection the liver is greatly enlarged, and 
may encroach upon the normal thoracic area. The liver is 
tender upon palpation. The jaundice is pronounced. The 
spleen is greatly enlarged, being easily determined by palpa- 



5 28 



DISEASES OF THE DIGESTIVE TRACT. 



tion. If pain occurs in the splenic area, it is due to a peri- 
splenitis. Ascites does not occur. If fluid be found in the 
peritoneal cavity, its presence is due to complicating peri- 
tonitis. At some time in the course of the disease the appe- 
tite, which is at first lost, returns ; bulimia may even be a 
symptom. The general nutrition of the patient, however, 
suffers considerably, and he rapidly loses flesh and strength. 
The urine is diminished in amount, is concentrated, and of 
a high specific gravity, containing bile pigment. Polyuria is 
sometimes associated with marked improvement in the condi- 
tion of the patient. 

The course of the disease is protracted. From the onset 
of the icteroid symptoms the disease may last from four to 
twelve years. In the later stages of the disease the jaundice 
becomes more marked, hemorrhages develop, and an inter- 
mittent fever shows itself, death being due to asthenia or to 
complications. It occasionally happens that toward the close 
of the affection the liver begins to shrink in size. Arthro- 
pathies affecting the fingers and toes, and even some of the 
larger bones of the extremities, have been noted in the later 
stages of the disease. 

Complications. — These consist in peritonitis, myocarditis, 
and such changes in the heart as dilatation and hyper- 
trophy. Anemia occasionally occurs, and there is some slight 
degree of leukocytosis, from 9000 to 20,000 per cubic milli- 
meter. Urinary disease and albuminuria are rarer than in 
atrophic cirrhosis. Occasionally in the later stages of the 
disease the hemorrhagic diathesis develops. There may be 
epistaxis, hemorrhages into the skin, from the gums, and from 
the intestinal tract. 



Diagnosis. — 



Liver 



Jaundice 

Ascites 



Spleen . . 
Hemorrhages 

Onset . . . 

Duration . . 



Atrophic Cirrhosis. 
Small, usually granular. 



Absent, as a rule; when pres- 
ent, not well marked. 
Marked. 



Increased in size. 
Principally from the stomach 

and bowel. 
Insidious. 

From two to three years. 



Hypertrophic Cirrhosis. 
Markedly increased in size ; 

granular element not well 

marked. 
Always present and well 

marked. 
Absent ; occasionally occurs 

toward the close of the 

disease, and often then 

not well marked. 
Markedly increased in size. 
Also marked from other 

parts. 
With recurring attacks of 

gastric disturbance. 
From five to ten years. 



ACUTE YELLOW ATROPHY OF THE LIVER. 529 

Atrophic Cirrhosis. Hypertrophic Cirrhosis. 

Complications . Chronic contracted kidney Very rare, 
and tubercular peritonitis 
comparatively frequent. 

Age After the fortieth year. Usually before the fortieth 

year. 

Prognosis. — The prognosis is always unfavorable. 

Treatment. — The treatment consists in directing attention 
to the catarrhal condition of the stomach and intestinal tract. 
The diet should be a bland, unirritating one, and alcohol should 
be avoided. Iodid of potassium and calomel in continuous 
small doses have been highly recommended. Arsenic occa- 
sionally is of use. 



ACUTE YELLOW ATROPHY OF THE LIVER, 

Definition. — An acute disease of the liver characterized by 
severe nervous symptoms, vomiting, and hemorrhages, with 
an associated diminution in the size of the organ, due to paren- 
chymatous and fatty changes. 

Synonyms. — Acute parenchymatous hepatitis ; icterus 
gravis. 

Etiology. — This is an exceedingly rare disease, and there 
have been but 250 cases recorded in medical literature up to 
the year 1894. It most frequently occurs between the ages 
of twenty and thirty, no age, however, being exempt. One 
case has been recorded four days after birth. Females are 
more frequently affected. Pregnancy appears to play a pre- 
disposing part. Season is without influence. No relation 
has been traced between syphilis and acute yellow atrophy ; 
the same is true of alcohol. Toxic elements appear to have 
a very close association, and the changes occurring in this 
condition resemble poisoning by phosphorus ; in fact, many 
symptoms are common to both conditions. It has been 
claimed by some authorities that mental emotion appears to 
predispose ; there is, however, no proof of this. 

Pathology. — The organ is flabby, greatly reduced in size, 
weighing as little as from 90 to 1 20 grams, being so greatly 
reduced that on opening the abdomen it is hidden under the 
diaphragm. The surface is smooth, the capsule is wrinkled, 
and the color a yellow or dull red, the gall-bladder usually 
being empty. The consistency of the organ is quite firm, this 
being due to the fact that the connective tissue and the blood- 
34 



530 DISEASES OF THE DIGESTIVE TRACT. 

vessels are more or less well preserved, while the secreting 
or essential portion is atrophied. 

Upon viewing the organ microscopically, a fine granular 
mass represents the greater portion of the hepatic cells. In 
many portions fatty degeneration has followed the cloudy 
swelling, and leucin and ty rosin crystals are often observed. 
The interstitial parts of the organ — that is, the fibrous connec- 
tive tissue — and the blood-vessels are quite distinct. The spleen 
is commonly enlarged. It has been suggested that the disease 
is caused by a micro-organism. 

Symptoms. — The disease begins as an ordinary attack of 
catarrhal jaundice. There is loss of appetite, nausea, vomit- 
ing, and epigastric distress, and this is followed in a day or two 
by the appearance of jaundice. One symptom is, however, of 
importance, and that is the occurrence of some rise in the 
temperature early in the course of the attack. This stage 
may last from five days to a week, but may vary considerably. 
The bowels are constipated ; the tongue is coated, and the 
pulse ranges from 60 to 70 per minute. The usual signs of 
jaundice in the skin are apparent. As a rule, about this time 
a sudden change occurs in the clinical picture ; there is 
marked, repeated, and severe vomiting, the patient rapidly 
becoming drowsy, semiconscious, and often delirious ; the de- 
lirium may be maniacal, and the jaundice becomes intensified 
and of a greenish hue. The tongue is dry and brown ; the 
pulse is rapid — from 120 to 140 per minute ; and the respira- 
tion is quickened. The temperature falls, becoming subnor- 
mal. The vomiting has been almost continuous ; the vom- 
ited matter now shows traces of blood. Enterorrhagia may 
occur, the stools being dark and offensive. There may be 
epistaxis and bleeding from the mouth, and petechias may 
occur. In women metrorrhagia, and in pregnant women 
abortion or premature birth, occurs. Associated with these 
symptoms, marked changes occur in the liver. 

Upon physical examination it will be noted that dullness 
in the hepatic area is markedly diminished ; in severe cases it 
may disappear altogether. 

In the urine characteristic changes are noted, and the 
amount of urine is diminished. Leucin, tyrosin, and albumin 
are present. Bile pigments are increased in amount. The 
second stage is of extremely short duration, lasting only 
two or three days, the patient dying with symptoms of deli- 
rium, and in convulsions. 



ABSCESS OF THE LIVER. 53 I 

Duration. — The duration in the majority of cases is about 
fourteen days, rarely exceeding three weeks. 

Prognosis. — The prognosis is absolutely unfavorable. 
Treatment. — The treatment is symptomatic. 



ABSCESS OF THE LIVER. 

Etiology. — The cause of purulent inflammation of the 
liver is the entrance of pyogenic micro-organisms into the 
organ. The methods by which they gain access are various. 

In abscess of the liver many organisms have been found 
associated, the most common being the streptococci, the sta- 
phylococci, the bacillus coli communis, Frankel's pneumo- 
coccus, the bacillus typhosus, the bacillus pyocyaneus, the 
ray fungus, and, in the tropical variety, the amoeba coli. The 
carriers of these micro-organisms are usually emboli, fish- 
bones, and parasites, such as worms. 

Two varieties of liver abscess are differentiated — the 
primary and the secondary. 

Those forms of abscess, originating from trauma, occur- 
ring from other organs from continuity of structure, as the 
gall-bladder or gall passages, are known as primary ab- 
scesses. 

Secondary abscesses are those which are due to micro- 
organisms which have been carried into the organ by the 
blood stream. Etiologically, it is impossible to draw well- 
defined lines of distinction. 

The most common are the secondary abscesses. These 
may occur from the morbid process being carried through 
the blood stream, which may be either through the hepatic 
artery or through the portal vein, and by some it is believed 
that it may even occur through the hepatic veins. 

Through the hepatic artery the infectious process arises 
from pyemia, from ulcerative endocarditis, gangrene of the 
lungs, putrid bronchitis, etc. 

When the mode of infection is through the portal vein, it 
is often due to appendicitis or ulcerative lesions of the bowel, 
or it may result from disease of the pelvic organs. This 
mode of infection most frequently arises in the course of 
tropical dysentery. Budd has claimed that an abscess in the 
liver in the course of dysentery is always of pyemic origin ; 
however, the autopsies of such cases do not confirm this, as 



532 DISEASES OF THE DIGESTIVE TRACT. 

there is most frequently only one large abscess, more rarely 
two. Abscess of the liver due to dysentery occurring in the 
tropics is very much more frequent in males than in females, 
and Europeans are much more likely to be affected than 
natives. This has been explained upon the basis that alcohol 
is a prominent predisposing cause, Europeans using more 
alcohol in hot climates than do the natives. 

Pathology. — Multiple, Pyemic, or Embolic Abscesses of 
the Liver. — When the micro-organisms are carried to the 
liver through the portal vein, multiple abscesses arise in the 
organ, usually without abscesses in other parts of the body ; 
but when the infection is conveyed to the organ through the 
arterial stream, abscesses are produced in many organs. From 
emboli the abscesses are rarely large or solitary. The liver 
containing pyemic abscesses is slightly enlarged, the surface 
usually being smooth and apparently normal. Upon section, a 
number of yellowish, rounded areas are exposed. These are 
filled with pus, the color of which varies, often being yellow- 
ish, grayish-green, or green. The edges of the abscess are 
irregular, and the cavities vary in size from a pin-point to 
masses about 6 cm. in diameter, rarely larger. The portal 
vein usually reveals suppurative pylephlebitis, and occasionally 
the biliary passages show a suppurative infection, which may 
extend to the gall-bladder. Upon microscopic examination 
the characteristics of acute suppuration are observed. Leu- 
kocytosis usually exists. 

Pathology. — Large Solitary or Tropical Abscess. — These 
abscesses are usually very large. They may be solitary or, 
more rarely, multiple. The liver is greatly enlarged by the 
abscess ; the organ may weigh 3500 grams. The abscess, as 
a rule, involves the right lobe. It frequently reaches a very 
large size, and in long-standing cases marked connective-tissue 
thickening occurs around it, so that it becomes hard and 
tough. The pus is usually thin and of a grayish or brownish- 
red color. 

Upon microscopic examination the liver near the abscess 
reveals interstitial change. The abscess wall shows a dense 
fibrous connective tissue. The innermost portion of the 
wall is composed of a number of round cells, polynuclear leu- 
kocytes, and amebae. Bacteriologic examination of the pus 
has demonstrated the fact that it may be sterile, or that it is 
infected with some of the micro-organisms of suppuration. 
The pus has been known to perforate into the peritoneal 



ABSCESS OF THE LIVER. 533 

cavity, the pleural cavity, the lungs, the colon, the hepatic 
and biliary vessels, and the inferior vena cava. 

Symptoms. — Pyemic Abscess of the Liver. — The symp- 
toms are those of pyemia, there being rigors, fever, and sweats, 
marked anemia and jaundice often being present. The liver 
is enlarged, and tender upon pressure ; however, diagnosis of 
the abscesses is difficult or often impossible. 

Tropical Abscess. — The liver becomes enlarged and tender, 
and jaundice, anemia, and wasting develop. The clinical 
manifestations vary somewhat, and large abscesses are occa- 
sionally present without marked disturbances ; therefore, the 
symptoms may be divided into the acute, subacute, and 
chronic forms. 

In the acute variety the constitutional symptoms are 
marked, there being extreme anemia, emaciation, marked 
rigors, fever, and sweating. There is pain in the region of 
the liver, which often radiates to the back and toward the 
right shoulder, or downward into the lumbar region. The 
liver is tender upon pressure, often giving rise to gastrointes- 
tinal disturbances, painful respirations, and cough, while peri- 
hepatitis and peritonitis may exist with the suppurative inflam- 
mation of the liver and give rise to severe pain. The pain is 
often of a throbbing character. 

Upon examination of the abdomen, enlargement is often 
noticed in the right hypochondriac region. Upon palpation 
a large, rounded, hard, and rarely fluctuating tumor is noted, 
and perhaps some edema of the abdominal wall. The chills, 
fever, and sweating occur with marked periodicity (daily) ; 
however, the patient may sink into the "typhoid state." 

In the subacute and chronic cases the onset is more insid- 
ious and the symptoms are not so grave. There may often 
be an absence of fever. Weakness becomes extreme. Diar- 
rhea may be present. In the acute cases the disease runs a 
short course of from fifteen to twenty days, the mortality be- 
ing high. In the subacute and chronic forms the course is 
much longer, varying from four or five weeks to months. 

Diagnosis. — When the disease is well advanced the diag- 
nosis as a rule is easy, and depends upon the painful enlarge- 
ment, which is sometimes fluctuating (if very superficial), the 
constitutional disturbances consisting of marked wasting, 
anemia, and the chills, fever, and sweating. The presence of 
the plasmodium in the blood is usually all that is required to 
differentiate it from malaria. 



534 DISEASES OF THE DIGESTIVE TRACT. 

Prognosis. — The prognosis of pyemic abscess is extremely- 
unfavorable, also that of tropical abscess, the mortality ranging 
from about 45^ to 80%. 

Treatment. — The treatment consists in the early evacua- 
tion of the abscess in suitable cases. The bowels should be 
regulated, being purged with calomel or salts. For the pain, 
opium in some form gives relief. When the septic phe- 
nomena are marked, free stimulation should be resorted to, 
whisky and strychnin giving good results. Quinin is often 
of use. For the anemia, iron and arsenic should be adminis- 
tered. The diet should be lio;ht and nutritious. 



BENIGN TUMORS OF THE LIVER. 

Fibromata. — These tumors are commonly so small that 
they do not give rise to distinctive symptoms ; therefore the 
antemortem diagnosis is impossible. It is stated that these 
tumors not infrequently occur in the liver. They may be situ- 
ated near the periphery or near the center. They exist in small 
masses, varying in size from a pinhead to a pea. On section, 
the knife meets w T ith considerable resistance. Their color is 
usually yellowish-white. 

Cavernous Angiomata. — These tumors are of but slight 
clinical significance, for when they are small, they do not give 
rise to distinctive symptoms. Only when they are large do 
they cause pressure symptoms, the latter condition being 
quite rare. Their usual size varies from that of a pinhead to 
that of a walnut. They occur in the aged, and are found in 
men oftener than in women. 

Lymphangiomata. — These tumors are very rare, but have 
been found in the transverse fissure of the liver. 

Adenomata. — These tumors are not infrequently met with in 
the liver, especially when the organ reveals cirrhotic changes. 
They are usually sharply circumscribed. . Fibrous connective- 
tissue septa may be pronounced in the tumors, so that they 
are divided into a number of segments. The cells may be 
arranged in an acinous or tubular manner. Adenomatous 
tumors of the liver are classified by some authorities as 
belonging to the malignant growths. Hoppe-Seyler -1 classifies- 
these tumors under the heading of malignant growths. 



1 Nothnagel's " Specielle Pathologie und Therapie." 



MALIGNANT TUMORS OF THE LIVER. 535 



MALIGNANT TUMORS OF THE LIVER. 

Carcinoma of the Liver. — Cancer of the liver is a rare 
disease. Lichtenstern found that out of 10,007 cases of 
cancer, only 6 c / c proved to be cases of carcinoma of the liver. 
It occurs most frequently between the ages of forty and 
sixty. This tumor is more frequently secondary, primary 
cancer being extremely rare. Of 258 cases of carcinoma 
of the liver collected by Hansemann 1 in the Berlin Patho- 
logical Institute, 25 were primary cancer of the gall-bladder, 
6 were primary cancer of the liver proper (2 of these being 
questioned), and 2 were primary cancers of the large bile- 
ducts. Primary cancer of the liver is more frequent in the male 
sex, and it seems that cirrhosis, malaria, and the abuse of 
alcohol are predisposing factors. Cancer is more frequent in 
women than in men, and is most often secondary to such con- 
ditions as carcinoma of the breast, of the uterus, and the ovary. 
It may also result from carcinoma of other abdominal organs, 
particularly the stomach and pancreas. It has been claimed 
that traumatism, parasites, and infectious processes in general 
are predisposing agents. Carcinoma of the gall-bladder fre- 
quently follows chronic irritation from gall-stones. Siegert 2 
found gall-stones associated with primary carcinoma of the 
gall-bladder in 95^ of the cases, while in secondary cancer 
he found gall-stone in only 15 J£ to \6 c /c of the cases. 
Primary cancer of the gall-bladder is more frequently met 
with in females than in males, and it is probably explained 
by the frequent occurrence of gall-stone in the female sex. 
Gall-stones and obstructive jaundice also seem to predispose 
to carcinoma of the biliary passages. 

Primary Carcinoma of the Liver. — The primary cancers 
of the liver may be quite large and massive, the liver being 
enlarged, and, as a rule, no cirrhosis accompanies the massive 
cancer. The capsule may be thickened, but is not adherent 
to the peritoneum. The primary cancer may be nodular, the 
cancer mass varying in size from a pea to a walnut, and in the 
majority of cases resembling the common variety of secondary 
carcinoma of the liver. The condition is also frequently 
accompanied by cirrhotic changes, with a decrease in the size 
of the orean. A third variety is known as the infiltration 



fe i 



1 " Berliner klin. Wochenschr.," 1890, No 16. 

2 "Virchow's Archiv," 1893, Bd. cxxxii, p. 353. 



53^ DISEASES OF THE DIGESTIVE TRACT. 

primary cancer, in which a number of small cancerous masses 
are thickly infiltrated throughout the liver substance, the organ 
showing thickening of the capsule and adhesions of the peri- 
toneum. Histologically, characteristics of carcinoma are 
present. 

Secondary Carcinoma of the Liver. — This form of cancer 
is usually easily recognized macroscopically on account of the 
tremendous enlargement of the organ, with the appearance of 
carcinomatous nodules, which are noted projecting above the 
surface in many places. They are of a grayish or yellowish r 
gray color, and the upper surface of the nodule is irregularly 
umbilicated, and the mass is quite distinctly circumscribed. 
These carcinomata show a great tendency to degenerate, and 
it is on account of this that the central portions recede and pro- 
duce the umbilicated appearance. The organ has been known 
to weigh eight kilograms. The infiltration may be so ex- 
tensive that the parenchyma is scarcely visible. Upon section, 
the liver is found to be somewhat more resistant to the knife 
than normally on account of the infiltration of the new growth. 
Bile-stained and hypqremic areas may be noted on the cut 
surface. The carcinomatous masses are of a grayish or 
yellowish color upon section. The degeneration sometimes 
leads to cyst formation. Histologically, the characteristics 
of secondary cancer are noted. On account of the pressure 
of the new growth, there is atrophy of the liver-cells. It 
will also be noted that cirrhotic changes are common in 
secondary cancers. 

Sarcomata of the Liver. — These are less frequently met 
with than carcinomata, and are usually secondary. Round- 
cell, spindle-cell, melanotic, and lymphosarcoma have been 
found as primary growths in this organ. 

Symptoms of Malignant Tumors. — The general cachexia 
of malignant disease is present, which may, indeed, be the 
first symptom of the condition. With this there is the presence 
of a tumor affecting the liver or the hepatic area. Commonly 
hard nodules may be felt upon the surface of the liver. 
Symptoms of compression occur. There is pressure upon the 
portal vein or the gall-ducts, and frequently there is for- 
mation of secondary growths in the peritoneum, lungs, etc-. 
Commonly, also, the symptoms of cirrhosis are present. The 
symptoms may be latent if the growth occur in the internal 
part of the liver; this is especially true of the adenomata 
which have been recognized only postmortem, the condition 



MALIGNANT TUMORS OF THE LIVER. 537 

not being suspected intra vitavi. The general symptoms 
are those of disturbance of nutrition, anorexia, disgust for 
food, especially meats and fats, great emaciation, and the 
malignant cachexia. The subjective symptoms of the patient 
are compression and weight in the right hypochondrium, soon 
giving place to dull pain, which may radiate to the right 
shoulder-blade. If pressure be exerted by the growth upon 
the biliary region, jaundice is a symptom. If the pressure" 
occur upon the portal vein or its radicals, ascites develops. 

The blood reveals secondary anemia, this often being ex- 
treme. The erythrocytes are greatly reduced, and the hemo- 
globin markedly diminished ; malignant leukocytosis occurs. 
Poikilocytosis develops if the anemia be marked. As a 
result of changes in the blood, hemic murmurs may be heard 
in the cardiac area, and edema is likely to occur. 

Fever is commonly present ; it may be either remittent or 
intermittent, and it may occur without the presence of compli- 
cations. As a rule, the temperature does not rise above 102 
F. When the malignant tumor is situated so as to occlude 
the common duct, symptoms of - obstructive jaundice arise, 
with enlargement of the gall-bladder. When the cancer in- 
volves the gall-bladder primarily, this organ becomes enlarged, 
and is painful upon palpation ; the cachexia and anemia develop, 
jaundice not necessarily being a symptom unless secondary 
nodules affect the larger bile-ducts, either in the liver or in the 
course of the common duct. The spleen shows no constant 
changes ; as a rule, it retains its normal size ; however, if the 
growth of the malignant tumor be slow, the spleen may show 
enlargement. The urine is usually diminished in amount, 
showing the presence of urobilin. Albumin and casts are 
occasionally found. In cases of melanosarcoma, melanin is 
found in the urine. Nervous symptoms occur, particularly 
late in the course of the affection. Pains in the region of the 
liver have already been referred to. Occasionally there are 
colicky pains. The patient is irritable and sleepless, and toward 
the close of the affection delirium and coma may occur, which 
are most probably due to cholemia. 

Prognosis. — The prognosis is absolutely unfavorable. The 
duration of the disease is variable, commonly about one year. 
The course is rapid in the forms complicated by cirrhosis, and 
in adenomata the duration of the disease is much longer. 

Treatment. — The treatment is expectant symptomatic. 



53$ DISEASES OF THE DIGESTIVE TRACT. 



DISEASES OF THE BILIARY PASSAGES. 

OBSTRUCTIVE JAUNDICE. 

Obstructive jaundice may arise from the following condi- 
tions : Catarrhal inflammation of the biliary ducts, stricture 
of the ducts, foreign bodies within the ducts, such as various 
parasites and stones ; from tumors occupying the lumen, 
catarrh of the duodenum, and from pressure from without, 
due to tumors of the pancreas, the stomach, the liver, the 
omentum, or the kidney ; and from aneurysms, large cysts, 
and enlarged glands. (See p. 31.) 

TOXEMIC JAUNDICE. 

This form of jaundice is called by some writers the hema- 
togenous or the hemohepatogenous variety. It results from 
the introduction of any one of a number of poisonous sub- 
stances into the stomach, and may arise in any of the infectious 
diseases. It sometimes occurs from snake-bites. (See p. 31.) 

CATARRHAL JAUNDICE. 

Etiology. — This often follows a gastro-intestinal catarrh 
due to indigestible food. It arises after a chronic catarrhal 
process, from chronic alcoholism. It sometimes follows cold 
and exposure in which the body has become chilled. Occa- 
sionally it may arise without assignable cause. Catarrh of 
the bile-ducts occurs in the course of the infectious diseases, 
such as malaria, typhus, and cholera. Poisoning by phos- 
phorus also gives rise to catarrh of the bile passages. Gall- 
stones, by irritating the mucous membrane, may give rise to 
catarrhal jaundice. It is more common in the early periods 
of life than in middle age, and more common in the male 
than in the female. In children the disease arises most often 
between the second and seventh years ; previous to this age 
it is rare. 

Pathology. — The mucous membrane lining the biliary 
passages in acute catarrhal jaundice can rarely be studied, as 
the disease never terminates fatally ; however, it is easy to 
understand that should the epithelial cells lining these ducts 



ICTERUS NEONATORUM. 539 

become swollen, granular, and be shed off and obstruct the 
onflowing bile, jaundice would follow. 

Symptoms. — The symptoms are those of gastro-intestinal 
catarrh — a sensation of weight in the epigastrium, anorexia, 
coated tongue, nausea, vomiting, headache, vertigo, and occa- 
sionally slight fever. The bowels are constipated. Rarely 
does diarrhea arise. The urine is diminished in amount, and 
dark in color, containing sediment. After these symptoms 
have continued for several days or a week, jaundice develops, 
showing itself particularly in the skin and in the urine. The 
feces become light, sometimes clay-colored, owing to the ab- 
sence of bile. These symptoms may last several weeks. When 
the tongue clears, the appetite returns and the signs of jaundice 
disappear, first in the urine and later in the skin. The dura- 
tion in uncomplicated cases is from three to four weeks, but 
complete recovery may be protracted for several weeks. In 
from one-third to one-half of the cases enlargement of the 
liver takes place. As a rule, there is no pain in the region of 
the liver. Fever is usually present for a few days. When 
jaundice develops, the temperature becomes normal or even 
subnormal. With the development of marked jaundice the 
pulse becomes slow. 

Prognosis. — As a rule, the prognosis is favorable. Only 
in the aged will long-continued jaundice produce dangerous 
symptoms. 

Treatment. — The diet is important ; it should consist of 
thin soups, of food that is free from fat, and of water in large 
amounts. Attention should be directed to the gastro-intes- 
tinal catarrh. Constipation should be corrected ; for this pur- 
pose small doses of calomel followed by salines are useful. 
The patient should remain in bed. When jaundice appears, 
the alkaline mineral waters are of use, such as Vichy or 
Carlsbad ; or phosphate of sodium may be administered in 
hot water. 

ICTERUS NEONATORUM. 

By this is meant a jaundice occurring in the new-born, in 
which speedy recovery takes place. It must not be con- 
founded with jaundice occurring in the new-born due to sep- 
ticemia or syphilis. Jaundice occurs in the new-born, ac- 
cording to statistics, in about two-thirds of the cases. It is 
much commoner in boys than in girls, and is likely to occur 
in children born after chloroform narcosis of the mother. 



540 DISEASES OF THE DIGESTIVE TRACT. 

As a rule, the jaundice shows itself upon the second or third 
day, first upon the face, then upon the breast. The conjunc- 
tivae become affected later than in adults. The jaundice may 
only last a few days — as a rule, to about the middle of the 
second week, but may last until the third or fourth week. 
Recurrences are rare. The general functions of the child are 
rarely interfered with. The urine is not discolored by bile, 
and, as a rule, albumin is not present. The bile pigments 
are absent. The feces are yellowish in color. The pulse is 
not slowed. Excretion of urine is increased. The prognosis 
in jaundiced children is as good as in those without jaundice. 
The jaundice does not require special treatment. 



SUPPURATIVE CHOLANGITIS. 

Suppurative infection of the biliary passages is rarer than 
simple catarrhal infection. It occurs particularly in old age 
as a result of gall-stones or parasites. It may occur as a 
complication or sequel of enteric fever, pyemia, or dysentery. 

Etiology. — In the majority of cases cholangitis is due to 
microbic infection. Micro-organisms find their way into the 
biliary passages from the bowel. The entrance of micro-organ- 
isms into the biliary passages does not necessarily lead to sup- 
purative inflammation, but very frequently results in a simple 
catarrhal process. The most common micro-organism pro- 
ducing cholangitis is the bacillus coli communis, either alone 
or combined with the staphylococcus albus or aureus, or with 
the streptococci. Parasites, such as ascarides, which find 
their way from the bowel into the biliary passages, may give 
rise to the affection. It also results from cancers of the duct. 

Pathology. — The pathology is that of acute suppuration 
of the mucous membrane, which leads to obstruction of the 
flow of bile. 

Symptoms. — These are rarely characteristic. Jaundice is 
not so intense as other symptoms, and may have preceded the 
suppurative cholangitis — as, for instance, from an attack of 
hepatic colic. Fever and enlargement of the spleen are im- 
portant symptoms, the fever being of the remittent type, with 
evening exacerbations. Occasionally it may be intermittent. 
As in all septic conditions, the fever may be accompanied by 
rigors and sweating, and is often due to the occlusion of the 
common bile-duct by gall-stone. It has received the name of 
Charcot's fever, or hepatic fever. In some cases, and especially 



cholelithiasis; gall-stones. 541 

if the gall-bladder be affected, pain in the hepatic area is a 
symptom. Commonly there are digestive disturbances, diar- 
rhea, and vomiting. 

Complications are pylephlebitis, septicemia, endocarditis, 
purulent meningitis, and, from extension from the gall-bladder, 
peritonitis. 

The course of the disease is chronic. The onset is mostly 
insidious. If due to cholelithiasis, the symptoms manifest 
themselves after the signs of the passage of the biliary calculus 
have disappeared. 

Prognosis. — The prognosis is unfavorable. 

Treatment. — This, consists in the thorough treatment of 
the cholelithiasis which is so frequently a cause of the affection. 
The remedies which are of most value are salicylic acid, salol, 
turpentine, and benzonaphthol. If the condition be due to 
ascarides, calomel and santonin are indicated. Surgical inter- 
ference has proved effective, by means of opening and drainage 
of the gall-bladder. 



CHOLELITHIASIS ; GALL-STONES. 

Gall-stones are composed of cholesterin and bile pig- 
ments, particularly bilirubin, with salts of calcium. Phos- 
phorus, magnesia, and other elements are occasionally inter- 
mingled. Some mucus is usually present. An analysis of 
gall-stones shows them to consist of about 90^ of choles- 
terin. The color of the stone depends upon the amount of 
biliary pigment present. If the stones consist almost entirely 
of cholesterin, they are nearly colorless or white ; if a small 
amount of biliary pigment is present, they are of a golden- 
yellow hue ; and if they possess much biliary pigment, they 
are of a golden-brown color or darker. 

The consistency depends upon the constituents ; thus, a 
fresh cholesterin stone may be easily broken up by the finger- 
nail. Freshly formed stones are usually soft. The shape de- 
pends upon the number of stones present and upon the position 
in which they are formed. If soft large stones are present, 
they show a flattened, smooth, mammillated and faceted sur- 
face. They may be rounded or elongated, with pointed ends, 
angular, or egg-shaped. When large, they are usually single. 
When they are small, several hundred may be present. As 
many as 7802 gall-stones were found in a case reported 



542 DISEASES OF THE DIGESTIVE TRACT. 

by Otto. It has been estimated that gall-stones have been 
found in from 5% to 10 fo of all postmortem examinations. 

They may occur at any age, and have been found in the new- 
born ; they are, however, rarely found under the ages of 
twenty-five or thirty. They occur more frequently in women 
than in men, and it has been supposed that pregnancy is a 
predisposing cause, as is also the wearing of tight corsets, 
which may press upon the front of the liver, depressing the 
fundus of the gall-bladder. This, combined with lack of exer- 
cise, would account for the greater frequency in the female sex. 
Catarrh of the bile-ducts and gall-bladder may lead to stag- 
nation of bile and to an increase in the amount of cholesterin. 
Farinaceous food may give rise to the formation of gall-stones, 
and in diseases in which nitrogenous food is largely partaken 
of, as in diabetes, gall-stones are rarely found. Gall-stones are 
formed most frequently in the gall-bladder. They may form 
in the larger gall-ducts, and rarely even in the smaller biliary 
passages of the liver. 

Pathology. — According to Naunyn, the production of 
gall-stones takes place as follows : Lime salts and cholesterin 
originate from the mucous membrane of the biliary ducts. 
This is especially marked when catarrhal inflammation exists. 
Epithelial cells and various micro-organisms seem to form the 
nucleus for the formation of the stone. Micro-organisms 
have been demonstrated in gall-stone. Commonly a great 
number of stones are met with, but a single stone may be 
present either in the gall-bladder or in the common duct. 
They may be smooth, oval, mulberry-shaped, or polygonal, 
containing a number of facets. They vary greatly in size. 
A single stone may fill up the entire gall-bladder, and some- 
times when many stones are present, they are as small as 
grains of sand. The stones are usually composed of large 
masses of cholesterin, which may be arranged in concentric 
layers, the outer portion of the stone being harder than the 
center. They also contain fatty and biliary acids, salts of 
lime and magnesium, copper, and iron. If obstructive jaun- 
dice continue for some time, cirrhotic changes usually develop 
in the liver. (See Biliary Cirrhosis.) Occasionally the stone 
may become firmly lodged in the common duct, and intersti- 
tial change take place in the walls of the duct so as firmly to 
encapsulate the stone. This may also occur in the gall- 
bladder. The stone may occupy the distal end of the common 
duct, or be in the ampulla of Vater, so as to form a ball valve 



CHOLELITHIASIS J GALL-STONES. 543 

— that is, the quantity of bile distends the duct by the ob- 
struction until the dilatation be so marked as to allow the 
escape of bile around the stone, and in some instances push- 
ing it back, in this manner giving rise to intermittent jaundice. 
Symptoms. — If the gall-stone remains quiescent and does 
not attempt to pass, symptoms do not arise. Occasionally 
there may be uneasiness in the right hypochondriac region, 
especially marked in changing the position of the body, or 
several hours after a meal. Rarely dull pains may occur in 
the right side of the epigastrium, which may also be present in 
the right shoulder-blade. The appetite may be variable. Occa- 
sionally nervous symptoms occur. The patient is irritable. 
Headache may be present, even neuralgias and migraine. If 
the abdomen be examined, the gall-bladder may be found 
enlarged. In rare instances stones may even be felt in the 
gall-bladder and be palpable through the abdominal wall. 
When the stone attempts to pass, distinctive symptoms are set 
up ; the condition is then known as hepatic colic. The attack 
may follow a hearty meal or violent exercise, and usually begins 
with decided pain, which sets in suddenly (frequently about 
midnight or sometimes in the late hours of the afternoon). 
The pain is described as boring, stabbing, and is so severe that 
the patient usually cries out. The pain is generally situated in 
the right hypochondrium, in the epigastrium, or in some cases at 
a point corresponding to the region occupied by the gall-blad- 
der. From here it may radiate upward into the chest or into the 
extremities, but most frequently through to the back and then 
into the right shoulder. Respiration, particularly inspiration, 
is painful ; the breathing is therefore accelerated, superficial, 
and costal. The pulse is feeble, often slow, but may be rapid. 
Commonly, the patient flexes the right leg upon the abdomen 
to relax the belly wall. The pain is intermittent in character, 
and when the stone has passed into the intestine, it ceases 
abruptly. Accompanying the pain there is usually vomiting, 
at first of food, and later of biliary material. There are chilly 
sensations, followed by a rise in the temperature to about 
103 F. or 104 F.; this is common. Sweating is rare. As a 
rule, the fever lasts but a few hours. One of the most im- 
portant symptoms of gall-stones is the development of jaun- 
dice, which, as a rule, does not occur at once, but twenty-four 
hours after the beginning of the biliary colic. The urine is 
high-colored, containing bile elements ; the stools are com- 
monly clay-colored. The presence of gall-stones in the feces 



544 DISEASES OF THE DIGESTIVE TRACT. 

is of great importance. Occasionally after well-developed 
symptoms of biliary colic no stone will be found in the feces 
upon careful examination. This may be due to several 
causes. Charcot has pointed out that during an attack of 
biliary colic the stone may fall back into the gall-bladder ; 
this condition is rare. The stone may not pass completely, 
and remain in the common duct, or it may be broken up in 
the bowel. That this last-mentioned fact occurs Naunyn has 
proved. 

The after-effects of biliary colic may arise from complica- 
tions, weakness, loss of appetite, nervous symptoms, loss of 
sleep, etc. Usually, however, the patient is comparatively 
well after the attack. Death during an attack of biliary colic 
is very rare. Occasionally rupture of the duct has taken place, 
bile being poured into the peritoneal cavity. If the stone 
does not pass, and remains in the common duct, cholangitis 
occurs, which may give rise to characteristic symptoms known 
as Charcot's intermittent fever or hepatic fever (described under 
Suppurative Cholangitis ; see p. 540). 

The following complications may occur : Intestinal ob- 
struction ; hemorrhages ; localized peritonitis ; ulceration of the 
bile-ducts, establishing a fistula between the common duct and 
the intestines ; stricture of the cystic or common bile-duct ; 
abscess of the liver ; empyema of the gall-bladder ; suppurative 
cholangitis ; extravasation of bile into the peritoneal cavity ; 
cancer of the gall-gladder, and others. 

Diagnosis. — Differential diagnosis must be made between 
biliary colic and appendicitis, hysteria, renal colic, and lead 
colic. The diagnosis of biliary colic depends upon the par- 
oxysmal sharp pain in the right hypochondrium, radiating to the 
back and the right shoulder-blade ; and upon the presence of 
vomiting and collapse, followed by jaundice. If the stone be 
arrested in the common duct, intense persistent jaundice and 
rarely the symptoms of Charcot's fever may be noted. Ap- 
pendicitis may be differentiated from biliary colic by the fact 
that the pain is not so paroxysmal, but is more continuous, 
and is often limited to " McBurney's point." There is usually 
the presence of tumor in the right iliac fossa ; pain rarely 
radiating to the right scapula. Jaundice, as a rule, does 
not occur. In hysteria the general neurotic temperament of. 
the patient must be taken into account ; the globus hys- 
tericus, the absence of collapse, and jaundice are impor- 
tant points. Renal colic is more closely associated with 



CHOLELITHIASIS J GALL-STONES. 545 

urinary symptoms, the pain radiating into the testicle and 
along the right genitocrural nerve. In lead colic the pain is 
persistent. It is not limited to the region of the gall-bladder, 
and does not radiate, and, as a rule, there is a blue line upon 
the gums ; paralysis of the extensors may be present. 

Prognosis. — Generally the prognosis of the individual 
attack is favorable. The prognosis is less favorable when 
hepatic fever occurs or when there are signs of a circumscribed 
peritonitis or empyema of the gall-bladder. If sudden rupture 
occur, with the effusion of bile into the peritoneum, the prog- 
nosis is hopeless. If complicated by carcinoma, the prognosis 
is bad. 

Treatment. — Prophylaxis. — This consists of appropriate 
diet, exercise, and general favorable hygiene. In women, tight 
lacing should be avoided. Warm baths, regular exercise in 
the fresh air, etc., should be recommended. The patient 
should avoid indulgence in sweets and starchy foods. Con- 
stipation should be avoided ; this may best be done by the 
use of waters, such as Carlsbad. Massage has been strongly 
advised. 

Treatment of the Attack. — Hot fomentations should be 
applied over the upper part of the liver. If the pain be severe, 
whiffs of chloroform may be inhaled ; however, in the majority 
of cases, relief only follows the hypodermic use of morphin. 
If the condition is not relieved by medical means, and the 
jaundice remains persistent, especially if symptoms of Charcot's 
fever occur, surgical interference should be resorted to. The 
indications for operation are as follows : In recurring hepatic 
colic without jaundice, with or without enlargement of the 
gall-bladder, especially if accompanied by great pain ; in jaun- 
dice following pain and symptoms of Charcot's fever ; in em- 
pyema of the gall-bladder ; in peritonitis starting from the 
right hypochondrium ; in cases in which adhesions remain 
which may prove painful ; in cases of fistula. 



35 



546 DISEASES OF THE DIGESTIVE TRACT. 



DISEASES OF THE HEPATIC VESSELS. 

DISEASES OF THE PORTAL VEIN. 

Obstruction of the portal vein may result from the growth 
of tumors pressing upon this vessel. The most common 
causes of compression are tumors of the stomach, pancreas, 
and the mesentery, and enlargement of the retroperitoneal 
glands, or from the liver itself. It may result from thrombosis, 
this being due to roughening of the endothelial coat, and is 
often of syphilitic origin. Obstruction may result from cir- 
rhosis, but complete obstruction from this cause is rare. 
Obstruction has been known to result from great numbers of 
the distoma hematobium in the finer capillaries. The throm- 
bus may organize, and the portal vein has been known to be 
completely occluded by fibrous connective tissue, nothing but 
the fibrous cord remaining, this condition being called pyle- 
phlebitis adhcesiva. 

Symptoms. — Narrowing of the portal vein through throm- 
bosis may give rise to symptoms which show the sudden onset 
occurring in the course of cirrhosis of the liver, chronic peri- 
tonitis, or tumors of the abdomen. They consist in the sudden 
appearance of symptoms due to stasis, marked epigastric 
pain, with vomiting and diarrhea, hematemesis and enteror- 
rhagia. In the course of a few days ascites and enlarge- 
ment of the spleen occur. The ascites soon leads to edema 
of the lower extremities, as a result of the pressure upon 
the vena cava. A caput medusae forms, and even cutaneous 
edema may occur. If, after paracentesis abdominis — which 
soon becomes necessary — has been performed, the liver is 
examined, it will be noted that it has decreased in size. Occa- 
sionally, jaundice occurs. In rare instances these symptoms 
just enumerated may come on gradually, and may closely 
resemble the development of atrophic cirrhosis. The urine 
is decreased in amount, and, according to some authorities, 
glycosuria occurs. This is explained by the fact that the 
sugar-forming elements are carried through the collateral cir- 
culation to the heart, and then through the general circulation, 
reaching the kidneys without having undergone metabolistic 
change in the liver. 

Duration. — The duration of the disease varies from a few 



PYLEPHLEBITIS. 547 

days to several years. If profuse hemorrhages occur, the 
disease may rapidly prove fatal. 

Prognosis. — The prognosis is always unfavorable, the only 
cases amenable to cure being those due to syphilis with 
gummata formation. 

Treatment. — The cases in which syphilis is suspected 
should be treated by mercury and iodid of potassium. From 
other causes the treatment is purely symptomatic. 



INFLAMMATION OF THE PORTAL VEIN.- 
PYLEPHLEBITIS. 

ACUTE PYLEPHLEBITIS. 

Synonyms. — Suppurative pylephlebitis ; ulcerative pyle- 
phlebitis. 

Etiology. — In rare instances an acute inflammation of the 
portal vein may be due to foreign bodies, which have tra- 
versed the wall of the bowel, and in this way reached the 
portal vein. It may also result from a purulent exudate 
from the lymph-glands reaching the portal vein. More fre- 
quently the inflammation begins in the terminal branches of 
the portal vein, which are in close relation to the abdominal 
viscera, particularly those of the bowel, especially the appendix 
vermiformis. Fistula in ano, hemorrhoids, and icarcinoma may 
cause the condition. It may result from trauma, such as 
might arise from the careless introduction of the rectal tube, 
and may follow abdominal operations. It may also result 
from inflammation of the uterus and its appendages or of the 
bladder, ulceration of the stomach, splenic abscesses, mesen- 
teric abscesses, purulent pancreatitis, and, in the new-born, 
from inflammation around the umbilicus. It may result from 
empyema of the gall-bladder, and from other inflammatory 
conditions of the biliary passages. 

Pathology. — At first the veins become thickened and the 
walls infiltrated with an inflammatory exudate ; a thrombus 
may then result ; often it is broken up, producing emboli, 
which lodge in the liver, giving rise to small abscesses. The 
walls of the vein may reveal ulcerated areas, and in some 
instances may rupture. This acute inflammatory infection is 
always of bacteriologic origin. Large solitary abscesses, as 
well as small ones, may arise in the liver from this cause. 

Symptoms. — The symptoms are those of septic processes 



54-8 DISEASES OF THE DIGESTIVE TRACT. 

joined to those of the primary affection. There is an irregular, 
high temperature, either intermittent or remittent in type, 
accompanied by chills, sweating, and collapse. Occasionally, 
the liver is enlarged, owing to cloudy swelling. The spleen is 
enlarged in the majority of cases. There is anorexia, vomiting, 
diarrhea, jaundice in some cases, and, toward the close of the 
affection, enterorrhagia. The urine is diminished in amount 
and is albuminous. 

Duration. — The duration of the disease is from two to six 
weeks. 

Prognosis. — The prognosis is always unfavorable. 

Treatment. — The treatment is expectant symptomatic. 



CHRONIC PYLEPHLEBITIS. 

As in other blood-vessels, sclerotic changes may take place 
in the portal vein, with thickening of the intima or with cal- 
careous infiltration. The vessel wall becomes inelastic, the 
lumen narrowed, and, as previously stated, may become oc- 
cluded (pylephlebitis adhaesiva). Syphilis is a cause of this 
condition. Weigert describes tuberculosis of the portal vein. 

Disease of the Hepatic Artery. — The hepatic artery may 
be the seat of aneurysm or of sclerotic changes. 

Disease of the Hepatic Veins. — Stenosis may result from 
compression through new growths or cicatrices, most often of 
syphilitic origin, which develop in the liver structure, or from 
inflammation of the hepatic vein, which is rarely primary. 
Thrombosis may also occur and give rise to occlusion. Emboli 
may lodge in the hepatic veins as a result of a regurgitating 
blood stream from the right heart, particularly the right auricle, 
sometimes during forced expiratory movements, as coughing. 

Inflammation of the Hepatic Veins. — This may be either 
acute or chronic. Acute inflammation is most frequent, and 
is due to suppurative inflammation of the liver, such as 
suppurative pylephlebitis, to echinococcus cysts, or to pur- 
ulent cholangitis. The chronic variety is most often due to 
syphilis. There are no symptoms by which this condition 
can be recognized. 



INFLAMMATION OF THE PANCREAS. 549 

DISEASES OF THE PANCREAS. 
INFLAMMATION OF THE PANCREAS. 

ACUTE HEMORRHAGIC PANCREATITIS. 

The whole or only a part of the pancreas may be involved 
by this process, in which the inflammation is combined with 
hemorrhage. 

Etiology. — Trauma may be a cause. Chronic alcoholism 
has been noted in a number of the cases ; it is, however, most 
commonly due to an extension of inflammation from the duod- 
enum to the pancreas through Virsung's duct. 

Pathology. — The organ may be enlarged and deeply 
stained with blood. On section, large areas or only puncti- 
form ones may be seen. Extensive fatty necrosis of the pan- 
creas and surrounding structures, as well as inflammatory 
changes, are noted. 

Symptoms. — As a rule, the symptoms appear suddenly. 
Severe pains in the epigastrium, in the region of the umbili- 
cus, nausea, vomiting, with constipation and signs of rapid 
collapse, are pronounced symptoms. There is great uneasi- 
ness, marked rapidity of the pulse (tachycardia), — 140 to 160 
per minute, — dyspnea, subnormal temperature, and rapid loss 
of strength ; death occurs from exhaustion in from a few hours 
to a few days. 

PURULENT PANCREATITIS (ABSCESS OF THE PANCREAS). 

(a) Primary Pancreatitis. — As etiologic factors, alcohol- 
ism, pregnancy, suppression of the menses, and poisoning 
from mercury have been given. Trauma may also be a cause. 
Necessarily, pyogenic organisms must find their way into the 
pancreas. The disease occurs much more frequently in men 
than in women, and arises most commonly between the ages 
of twenty and thirty. 

Pathology. — The organ is enlarged, and abscesses are 
found scattered throughout, or they may be more numerous 
in certain parts. The necrotic process may destroy a part or 
the whole organ, and through rupture the pus may find its way 
into the peritoneal cavity. 

Symptoms. — As a rule, the symptoms occur suddenly in 
the course of or following hepatic colic or digestive disturb- 



550 DISEASES OF THE DIGESTIVE TRACT. 

ance. There is violent pain, coming on suddenly in the epigas- 
trium, which is localized and does not radiate from the abdomen. 
However, this is not invariable, as cases have been recorded 
without pain. In rare instances pains may show themselves 
in the splenic region, the spleen being tender, pain being elicited 
in this area upon palpation. Nausea and vomiting, with eruc- 
tations, are almost constant symptoms, the vomited material 
often being bile-stained. With these symptoms there is rapidly 
oncoming and marked prostration. Fever of an irregular type, 
accompanied by rigors, is present, but in rare instances the 
fever may be absent. As a rule, constipation occurs. In 
rare instances diarrhea is present, which later may become pro- 
fuse. Occasionally, diarrhea may alternate with constipation. 
The feces may contain blood and fetid pus, the abscess having 
ruptured into the bowel. Albumin and fat may be present in 
the stool. The liver is enlarged, and also the spleen, but to a 
less extent. There is considerable tympany of the abdo- 
men. In some cases fluid may be found in the belly, or there 
may be other signs of accompanying peritonitis. Upon phys- 
ical examination the epigastrium is resistant, or even a tumor 
may be found in the abdomen. The urine is usually of low 
specific gravity — 1002 to 1005. Peptone, albumin, sugar, and 
indican have been found present. Jaundice occurs in about 
25^ of the cases. In cases that run a chronic course marked 
emaciation and petechia, or other purpuric manifestations, may 
occur. 

Treatment. — The treatment is surgical. 

(b) Secondary Acute Purulent Pancreatitis. — The sec- 
ondary variety may arise from inflammation of surrounding 
organs from continuity of structure, also in the course of 
pyemia, puerperal fever, and from malignant disease of the 
pancreas or other surrounding organs. Rarely it may result 
from acute peritonitis. 

The symptoms are those of the underlying affection, linked 
with those just enumerated in the primary variety. 



GANGRENOUS PANCREATITIS. 

Gangrenous pancreatitis may result from suppurative in- 
flammation or in the course of chronic pancreatitis. Necrosis 
may occur from hemorrhage. It is doubtful whether fat 
necrosis of the pancreas ever leads to gangrene ; some authori- 
ties, however, have recorded such instances. Gall-stones may 



TUMORS OF THE PANXREAS. 551 

give rise to the affection, and it may be produced from unknown 
causes. 

Pathology. — The pancreas may be partially or entirely in- 
volved. Sometimes the organ is of a brownish-red or green 
color, emitting a stench which is common to gangrenous affec- 
tions. Rupture into the intestine with discharge of the gan- 
grenous mass has been recorded. General peritonitis does 
not usually occur ; more commonly a localized process is en- 
countered. 

Symptoms. — The causes which give rise to gangrene of 
the pancreas are so varied that the symptomatology neces- 
sarily depends upon the etiologic factors. As a rule, violent 
pains, which are limited to the epigastrium and radiate in all 
directions, are common. Nausea with vomiting, tympanites, 
tenderness, symptoms of collapse, such as a rapid pulse, 
irregular fever, with a dry tongue, etc., are present. Obstruc- 
tion of the bowel is a common symptom. If rupture occurs 
in the retroperitoneal space, a tumor may be noted upon 
palpation. 

Diagnosis. — The diagnosis must be made by exclusion. 

CHRONIC INDURATIVE PANCREATITIS. 

This may arise from two groups of causes — from indurative 
inflammatory processes, as a result of disease of the vessels, 
such as arteriosclerosis and endarteritis obliterans, especially 
as a result of syphilis and alcoholism ; and, secondly, from 
chronic indurative inflammatory processes, or obstruction and 
narrowing of the pancreatic duct. The organ may be small 
and very hard. Rarely is it larger than normal. Sclerosis 
and atrophy of the pancreas are of interest, as they bear 
an etiologic relationship to diabetes mellitus ; and, also, if 
the sclerotic process be present in the head of the organ, 
obstruction of the common bile-duct from contracture may 
result. 

TUMORS OF THE PANCREAS. 

BENIGN TUMORS. 

These tumors are extremely rare in this organ. Adenomata 
have been met with and recorded in recent medical literature. 
Extirpation of these tumors has resulted in recovery. 



55 2 DISEASES OF THE DIGESTIVE TRACT. 



MALIGNANT TUMORS OF THE PANCREAS, 

Carcinomata of the Pancreas. — Carcinomata of the pan- 
creas are rare. In 23,611 autopsies collected by Biach, 1 of 
diseases of the pancreas, 29 carcinomata of the pancreas were 
found. Primary carcinoma is most frequent in the head of the 
pancreas, next in frequency being the body, and the rarest situ- 
ation being in the tail. Secondary cancers of this organ are 
also encountered. The scirrhous form is most common, the 
encephaloid variety being rare. Males are more frequently 
affected than females, the most common age being between the 
fortieth and the seventieth years. 

Cachexia, as in malignant disease of other organs, is also 
noted here, with progressive increasing weakness and loss of 
weight ; the presence of a tumor in the region of the pancreas, 
with pain, which may be paroxysmal, are symptoms. Fatty 
stools may occur. If the cancer affect the head of the pancreas, 
jaundice is likely to appear. Diabetes is met with in cancer 
of the pancreas. On examination of the patient, the tumor, 
which is tender upon pressure, may be felt. The disease in- 
variably terminates fatally, usually running a rapid course. 

Sarcoma. — Primary sarcoma of the pancreas is an exceed- 
ingly rare affection, but secondary melanotic sarcoma is more 
common. 

Treatment of Malignant Tumors of the Pancreas. — The 
treatment consists in relieving the pain by the administration 
of opium in some form. Operation should be advised if the 
condition be diagnosticated early. 

PANCREATIC CYSTS. 

They may be due to blocking up of the pancreatic duct, 
giving rise to retention cysts. Proliferation cysts and reten- 
tion cysts of the smaller ducts are also encountered. Inflam- 
matory changes of the pancreas may give rise to cysts. The 
cyst may develop so that the stomach is pushed upward, or 
it may form above the lesser curvature, displacing the stomach 
downward ; or it may be so large as to lie beneath the colon ; 
and occasionally it is found in the left hypochondrium. 

Symptoms. — Frequently the condition can not be diagnos- 
ticated. As a rule, a tumor is found occupying a position 
between the liver and spleen. There is rapid emaciation, and 

1 Nothnagel's " Specielle Pathol ogie und Therapie." 



TUMORS OF THE PANCREAS. 553 

paroxysmal attacks of pain may occur. Symptoms of dia- 
betes, such as glycosuria, are likely to occur. An explora- 
tory puncture may be undertaken in doubtful cases, when, 
if fluid from a pancreatic cyst be found, it will contain epithelial 
cells, red blood-cells, and pancreatic ferments. It is strongly 
albuminous, in contrast to the fluid from echinococcus cysts, 
which does not contain albumin. 

Treatment. — The treatment is surgical. 

PANCREATIC CALCULL 

Pancreatic calculi are rare. There are usually many stones, 
and they scarcely ever attain a large size. The largest stone 
recorded was found by Schupmann ; it was 2 y 2 inches long 
and from 5 to 6 lines in diameter. It weighed two ounces. 
The stones are usually of a grayish or yellowish-white color, 
and rarely darker. The origin of the stone has by no means 
been satisfactorily explained. The calculi are composed chiefly 
of carbonate and phosphate of lime, and contain cholesterin 
plates. They give rise to cystic formation of the ducts and 
to interstitial changes in the organ. The affection is most 
common in males, and arises most often between the ages of 
thirty-five and forty-five. 

Symptoms. — If the stone be firmly situated, no symptoms 
arise, but upon passage colicky pains develop, accompanied by 
nausea, vomiting, and symptoms of collapse. Diarrhea, with 
the occurrence of fat in the stools, and glycosuria have been 
noted. 

Diagnosis. — The diagnosis depends upon the appearance 
of the characteristic concretions in the feces, the diabetes, the 
fatty stools, the colicky pains, salivation, and jaundice. 

Treatment. — It has been experimentally determined that 
pilocarpin increases the flow of the pancreatic juice ; hence, 
hypodermics of pilocarpin are indicated in pancreatic colic. 
For the pain itself, opium is necessary ; and hot fomentations 
to the epigastrium in the region of the pancreas are grateful 
to the patient. If abscess or cyst formation take place, sur- 
gical interference is necessary. 

HEMORRHAGE INTO THE PANCREAS. 

Etiology. — Hemorrhage may result from trauma. It is 
occasionally due to a dilated right heart, from the general 
venous stasis which is apt to follow this condition. It is 



554 DISEASES OF THE DIGESTIVE TRACT. 

believed by some to be of nervous origin. The hemorrhage 
may be either large or small, depending upon the cause. 

Symptoms. — Pain in the epigastrium, corresponding to the 
region of the pancreas, with the appearance of shock, frequent 
vomiting, and occasional diarrhea, are the diagnostic criteria. 
The pulse becomes rapid and feeble, and the temperature may 
be subnormal. Recovery may take place from small hemor- 
rhages ; profuse hemorrhages are commonly fatal. 

Treatment. — The treatment consists in absolute rest, the 
use of opium in some form, and the local application of ice. 

FAT NECROSIS OF THE PANCREAS. 

This affection is associated with some of the diseased con- 
ditions of the pancreas. Yellowish necrotic areas varying 
from the size of a miliary tubercle to that of a pea, or some- 
times as large as a hen's tgg, are found in the pancreas, 
in the surrounding tissues, and sometimes in the abdominal 
wall. They are most often noted in the interlobular spaces 
of the pancreas. Other seats in which these fat areas can be 
found are in the omentum, the perirenal fat, the mesentery, 
the abdominal wall, and occasionally in the bone-marrow. 

Experiments performed by Katzand Winkler 1 show that by 
ligation of the pancreatic duct, and also by ligation of the 
glands at various parts, fat necrosis was produced, accompanied 
by an enormous leukocytosis. In one case, in which a dog 
was operated upon, there were 12,500 leukocytes per cubic 
millimeter; two days following the operation there were 3 10,000 
leukocytes. The dog died upon the ninth day after the opera- 
tion ; marked necrosis of the pancreas was found, but no 
purulent material. 

The causes of fat necrosis are not definitely understood. It 
has been suggested by Langerhans that it is due to the libera- 
tion of the fat-splitting ferments of the organ into the digestive 
tissues. Bacteriologic examinations of the necrotic areas show 
that they are sometimes sterile and sometimes infected by 
various organisms. Diabetes mellitus has been found asso- 
ciated with fat necrosis. 

Symptoms. — The symptomatology shows wide variations. 
The disease may exhibit the symptoms of acute intestinal 
obstruction, or the symptoms of retroperitoneal tumor, or of 
perforating peritonitis. In other cases the symptoms may 

1 Oser, " The Diseases of the Pancreas," vol. xvm of Nothnagel's " Specielle 
Pathologie und Therapie." 



TUMORS OF THE PANCREAS. 555 

resemble cholelithiasis, with severe colic and collapse, or the 
symptoms may resemble a toxemia due to a severe infection 
or active poison. 

RUPTURE OF THE PANCREAS. 

This is an exceedingly rare condition, as the pancreas is so 
deeply situated in the abdomen, being well protected against 
trauma ; the force must be applied directly backward in the 
upper part of the abdomen. The symptoms are those of 
shock, similar to those in severe internal hemorrhages. 



PART V. 
DISEASES OF THE KIDNEYS. 



ACTIVE CONGESTION. 

Synonyms. — Active hyperemia ; hyperemia. 

Active hyperemia is the first stage of inflammatory condi- 
tions of the kidney ; it occurs when one kidney is doing work 
for the other (compensatory hyperemia), also in hypertrophy 
of the left ventricle, from diabetes mellitus and diabetes insipi- 
dus, and in certain diseases of the nervous system, particularly 
of the medulla oblongata and the sympathetic nerves ; lastly, 
from certain irritants and diuretics, such as cubebs, turpentine, 
etc. The organ is large, of a dark red color, and upon sec- 
tion blood drips from the cut surface ; it is also slightly more 
friable. 

PASSIVE CONGESTION- 

Synonyms. — Passive hyperemia ; congestion ; cyanotic in- 
duration. 

Etiology. — This condition is most commonly due to valvu- 
lar heart disease when failing compensation develops, the blood 
being held back in the larger veins, so that it can not escape 
from the organ. It may also occur from mechanical compres- 
sion of the venous trunks, such as a tumor pressing upon the 
renal veins or upon the vena cava. 

Pathology. — The kidney is larger than normal, especially 
in its shortest diameter, it therefore being somewhat rounded. 
Its color is reddish-blue (cyanotic); the capsule is found to 
retract slightly when the knife is inserted into the organ, and 
is easily stripped. Upon section the knife meets with more 
resistance than normally, owing to the kidney being indurated. 

556 



PASSIVE CONGESTION. 557 

The cut surface freely drips dark colored blood, and the Mal- 
pighian bodies and the pyramids stand out prominently, and 
are deeply stained, being in marked contrast to the surround- 
ing kidney structure. Microscopically, it will be found that 
the veins are dilated, and frequently ^clerotic changes are found, 
particularly about the Malpighian ducts. If the congestion be 
long continued, the kidney becomes smaller, owing to marked 
interstitial change. The color then becomes lighter, often not 
being so deeply stained as the normal organ. The surface is 
irregular ; the fibrous capsule strips with difficulty ; the organ 
is very tough (cyanotic induration), and cuts with much re- 
sistance. Upon microscopic examination it will be found that 
there is a marked increase in the fibrous connective tissue 
between the tubules, and the Malpighian bodies may be re- 
placed by the interstitial tissue. 

Symptoms. — The diagnosis of this condition must be made 
principally through the urine. The urine becomes diminished 
in amount, the color darker than normal ; it is strongly acid 
in reaction, with a decided increase in the specific gravity — 
from 1025 to 1030. In consequence of the diminished amount 
of fluid secreted, the urates deposit in large amounts, showing 
the characteristic " brickdust " sediment. The urine may con- 
tain bile pigments, particularly urobilin. Sooner or later 
albumin shows itself, usually in small amounts. Tube-casts, 
particularly hyaline, occur with the albumin, and there 
are a few leukocytes. Exceedingly rarely, erythrocytes are 
present, and then only in small amounts. These probably 
are found in the urine as a result of the rupture of the blood- 
vessels into the tubules. These changes which occur in the 
urine are really the results of congestion due to lessened 
arterial and increased venous pressure. Fever does not occur 
with this condition. Accompanying this urinary affection there 
is, as a rule, marked dyspnea and cyanosis, gastro -intestinal 
catarrh, enlargement of the liver with jaundice, hemorrhoids, 
headache, and drops}*, these symptoms all being due to the 
same cause — ruptured compensation in valvular heart disease. 

Prognosis. — The prognosis is usually favorable, except in 
those cases in which interstitial changes take place. 

Treatment. — Efforts should be made to increase the mus- 
cular activity of the heart. Cardiac tonics are indicated, digi- 
talis deserving the front rank. If digitalis be contraindicated, 
strophanthus, caffein, and spartein may be used as substitutes. 
The patient should remain in bed. Active purgation should 



55$ DISEASES OF THE KIDNEYS. 

be instituted, this being best accomplished by calomel, which 
is at the same time a diuretic, and may be followed by salines. 
The diet should consist of milk. 



ACUTE DIFFUSE NEPHRITIS. 

Definition. — Acute diffuse nephritis is an acute inflamma- 
tion of the kidney involving the entire anatomic structure 
of the organ, although in the majority of cases the epithelial 
cells are principally affected. 

Synonyms. — Acute parenchymatous nephritis ; acute 
tubular nephritis ; acute Bright's disease ; acute desquama- 
tive nephritis ; acute exudative nephritis. 

Etiology. — Acute nephritis is due to the direct irritation of 
some toxic substance brought to the kidney from the blood ; 
thus, the infectious diseases frequently give rise to it, — scarlet 
fever, diphtheria, yellow fever, erysipelas, enteric fever, malaria, 
smallpox, croupous pneumonia, acute rheumatic fever, and in 
some of the more chronic infectious diseases, as syphilis and 
pulmonary tuberculosis. The disease may result from trau- 
matism and suppuration. An important cause is exposure to 
cold and wet. The disease arises occasionally in the course 
of pregnancy. Finally, certain drugs give rise to nephritis. 
The disease has followed the internal use of cantharides, 
chlorate of potash, turpentine, squills, carbolic acid, corrosive 
sublimate, and some of the balsams. Alcohol exceedingly 
rarely gives rise to acute nephritis. 

Pathology. — The changes in the kidney vary greatly, de- 
pending upon the intensity of the irritation and upon the 
vascular supply of the organ. The kidney is always enlarged, 
the size, however, varying somewhat. The fibrous capsule 
is tense, and when incised, it is found to retract slightly. 
It strips quite easily unless chronic interstitial changes pre- 
ceded this condition, binding the capsule to the kidney sub- 
stance. The surface of the kidney in the early stages is 
smooth and of a dark, reddish-gray color. Upon section 
the organ is found to be of a lessened consistency, and quite 
friable. The cut surface drips blood, the pyramids and the 
Malpighian bodies are found deeply stained, and the entire 
surface of a deeper color than normal in the early stages ; 
later, this color changes to a yellowish-gray. It will also be 
noted that the entire width of the cut surface is increased, this 



ACUTE DIFFUSE NEPHRITIS. 559 

being most marked in the cortical portion, so that the cortex 
equals one-half of the width. 

Anatomically, three varieties have been differentiated : The 
first one, which is very red, is called the hyperemic or hem- 
orrhagic ; the second is a pale form ; and the third is a 
mottled, which should be classed as an intermediate condition 
between the pale and the hyperemic. 

The microscopic examination shows that the epithelial cells 
lining the tubules are affected. When the epithelial cells of 
the kidney, both of the glomeruli and the remaining parts of 
the tubules, are affected, the condition should be properly 
spoken of as parenchymatous nephritis. If the changes be 
more pronounced in the glomeruli, it may be spoken of as 
glomerulonephritis ; or if the changes be more marked in the 
tubules, tubular nephritis ; and if the interstitial parts also 
show acute inflammatory lesions, as well as the tubules and 
the glomeruli, the condition is known as diffuse nephritis. 

The epithelial cells lining the tubules at first become swollen 
and granular (cloudy swelling), so that the lumen of the tubule 
is decreased in diameter and the width of the tubule is in- 
creased, therefore giving rise to swelling of the organ. Later, 
the epithelial cells may become very irregular in outline, and 
show fatty changes, or sometimes hyaline degeneration. The 
nuclei of the cells share in the degenerative process, and in 
stained preparations they are with difficulty demonstrated, or 
the staining reaction becomes somewhat modified. In the 
lumina of the tubules hyaline and granular material, loose 
epithelial cells, leukocytes, and red blood-corpuscles may be 
noted. It will be found that the larger or terminal tubules 
rarely show changes in the epithelial lining, but the lumina 
are filled with casts, red blood-cells, leukocytes, and degen- 
erated epithelial cells which have been washed out from the 
smaller tubules. The interstitial part of the organ will show 
that the blood-vessels are dilated, and leukocytic infiltration 
is always found. Hemorrhages into the kidney substance 
occur, particularly in acute diffuse nephritis. 

Symptoms. — The disease may begin suddenly or gradu- 
ally. A sudden onset is more likely to take place after ex- 
posure to cold or wet, or in the course of one of the infec- 
tious diseases, particularly scarlet fever, the patient having 
several rigors, followed by fever, and pain in the loins, which 
is increased by pressure, and general malaise. Edema devel- 
ops rapidly ; the urine becomes scanty and high-colored, and 



560 DISEASES OF THE KIDNEYS. 

uremic symptoms, such as vomiting and convulsions, occur. 
This is a rare form of onset. The mode in which the dis- 
ease commonly shows itself is in the gradual onset of all the 
symptoms. The urine becomes scanty and high-colored. 
In fact, the symptoms may be so mild that attention 
is first directed to the case by the development of uremic 
phenomena. Ordinarily, after several days some slight facial 
edema, particularly about the eyelids, makes its appearance. 
As a rule, this is noticed only at the onset, in the morning 
upon awakening, and passes away in a few hours. Later in 
the course of the disease it becomes permanent, and the 
dropsy becomes more general. In many cases edema is the 
first symptom of the disease. As the affection progresses, 
the digestive organs begin to manifest symptoms. Nausea 
occurs, which soon passes into constant vomiting. Constipa- 
tion, which has at first been present, gives place to diarrhea. 
There is dull headache, with pains in the back and loins, 
edema of the feet, dryness of the skin, and dyspnea. The 
face becomes pale and puffy, and is quite characteristic. The 
urine is markedly diminished in quantity ; even anuria may 
occur. Fever, as a rule, is absent ; when present, it is due 
to the primary condition causing the nephritis. When the 
disease is arrested, the edema gradually disappears, nausea 
and headache cease, the skin becomes moist, the urine is more 
profuse, and the patient gradually recovers. This is the rule 
in nine -tenths of the cases. If this does not take place, -the 
albumin and the edema do not entirely disappear, the patient 
is troubled with dyspnea and weakness, and the acute form 
merges into the chronic variety. In cases that terminate fatally 
the symptoms increase in severity ; nervous phenomena de- 
velop, such as convulsions, followed by coma ; edema of the 
lungs, or pericarditis. The three terminations of acute nephritis 
are, then, complete recovery, merging into the chronic variety, 
and death. The exact diagnosis of acute nephritis can be 
made only by an examination of the urine. 

The Urine. — The urine is always decreased in amount ; it 
may be as little as 50 c.c. in twenty-four hours, but even such 
cases have resulted in recovery. The color is dark red and the 
urine is turbid, blood being present. The amount passed dur- 
ing the night generally shows less blood than that passed dur^ 
ing the day. The specific gravity is from 1020 to 1030, and 
upon testing the urine large quantities of serum-albumin are 
found, from y 2 % to 1 f • The quantity of urea is usually less 



ACUTE DIFFUSE NEPHRITIS. 56 1 

than normal. Under the microscope, hyaline, granular, and 
epithelial casts are noted, with renal epithelium, red blood- 
cells, and granular matter. Hematoidin crystals, either free 
or in cylinders, are noted, as are also various micro-organisms. 
Oxalate of lime and uric acid are not infrequent. In some 
cases blood-casts are found. 

Dropsy.— Next to the urine in importance is dropsy. It 
shows itself first in the face beneath the eyelids, then about 
the ankles, about the tibia (pretibial edema) and other parts 
of the body. Serous effusions also take place about the loose 
tissues of the genitals and in the serous cavities. The facies of 
the patient is characteristic. The face is pale and puffy, the 
eyelids are swollen, and the skin is dry and coarse. 

The Pulse. — As a rule, the pulse is not markedly accel- 
erated ; it may even in rare cases become slow — from 3 5 to 
50 ; the sphygmograph, however, reveals high tension with- 
out hypertrophy of the left ventricle. 

The Gastric Symptoms. — Nausea, vomiting, and diarrhea 
occur, although not so frequently as in the chronic forms. 
The nervous symptoms are most often due to uremia. 

Diagnosis. — The direct diagnosis depends upon the history 
of the case, the general appearance of the patient, and the ex- 
amination of the urine, in which blood, with albumin and casts, 
are present. 

Prognosis. — The majority of cases recover entirely ; some 
few, however, merge into the chronic variety. Death is a rare 
result. A small, frequent, soft pulse is an unfavorable sign, 
as is the development of uremia. Inflammatory complications 
and the presence of fluid in the serous cavities are unfavor- 
able symptoms. In favorable cases recovery takes place 
within four weeks ; however, many cases may go on for 
months and still recover. Cases, as a rule, which terminate 
in death are of short duration. 

Treatment. — The patient should be put to bed, warmly 
clad, preferably with woolens next to the skin. The tempera- 
ture of the room should be from 68° F. to 7 r 2° F., with good 
ventilation. Daily sponging with warm water and general 
friction of the skin are of use. Sweating should be induced 
by the use of the hot pack or by other means ; this is recom- 
mended by many. The diet is most important. The best 
food for the acute and subacute cases is milk ; three quarts 
during the day is sufficient. Some of the alkaline mineral 
waters, as Seltzer and Vichy, may be mixed with the milk. If 
36 



562 DISEASES OF THE KIDNEYS. 

the milk does not agree, kumiss or buttermilk may be sub- 
stituted. Water should be administered freely. Calomel 
in fractional doses is useful. This may be followed by a 
saline, even if there be no tendency to constipation. Dry 
cups are occasionally employed to relieve the kidneys, with 
the hope of exciting the flow of the urine. Liquor ammonii 
acetatis, citrate of potash, and benzoate of soda may be given 
as diuretics. Diuretin in 15 -grain doses, administered three or 
four times during twenty -four hours, is of use in some cases. 
Digitalis, as a rule, is not indicated. In convalescence gentle 
exercise may be allowed, great precautions being taken against 
cold. Alcohol and tobacco should be avoided. For the 
anemia, which may persist, iron in some form is of value. 
The treatment of uremia is described on page 588. 

. CHRONIC DIFFUSE PARENCHYMATOUS 
NEPHRITIS. 

Synonyms. — Diffuse parenchymatous nephritis ; chronic 
desquamative nephritis ; chronic tubular nephritis. 

Etiology. — This is the most common form of renal disease, 
three varieties being found at autopsy, which differ from one 
another in their gross and microscopic appearances. In all, 
however, the change begins in the epithelial cells of the kid- 
ney, being a parenchymatous inflammation. The symptomat- 
ology of the three conditions being somewhat different, the 
clinician is often enabled to determine with which form he is 
dealing. 

The varieties of chronic parenchymatous nephritis are : 
(1) The variety known as the large white kidney ; (2) the 
chronic hemorrhagic kidney ; and (3) the mottled or cirrhotic 
kidney. 

The affection is most common between the twentieth and 
the fiftieth years of life, the disease rarely occurring in early 
adult life or in the aged, the male sex being more frequently 
affected than the female. Heredity is an important element 
in the causation of the disease. It is particularly a disease of 
the poorer class, especially those living amidst unsanitary sur- 
roundings, in damp buildings, etc., and of those who are ex- 
posed to the vicissitudes of the weather. Alcoholism is per- 
haps the most important etiologic factor, the disease occur- 
ring most frequently in the steady drinker who takes his daily 
quantum of alcohol, and not in the one who becomes periodi- 



CHRONIC DIFFUSE PARENCHYMATOUS NEPHRITIS. 563 

cally intoxicated. In general terms it may be said that when 
acute nephritis has lasted longer than eight months, the disease 
may be considered chronic. The chronic forms are likely 
to develop from the acute variety, especially that form due to 
pregnancy or to scarlatinal or malarial infection. The dis- 
ease occasionally occurs in the course of chronic endocarditis. 
According to Bamberger, J c / of the cases of chronic nephri- 
tis may be attributed to endocarditis. The disease also occurs 
in the course of pulmonary tuberculosis, chronic suppurative 
processes, and syphilis, and in the gouty and the lithemic. 

Pathology. — The various forms of chronic parenchymatous 
nephritis have this in common, that the kidney is usually in- 
creased in size. The extent of the involvement varies consid- 
erably, so that one form often merges into another — that is, a 
distinct line of demarcation can not well be drawn between 
the various varieties. In chronic parenchymatous nephritis 
the epithelial cells, especially those of the cortical portion of 
the kidney, are almost exclusively involved, the lesion vary- 
ing from cloudy swelling to marked fatty degeneration. X ne 
epithelium lining the tubules becomes desquamated and 
irregular in outline, often blocking up the opening of the 
tubule, which may contain leukocytes, epithelial cells, etc. A 
certain amount of interstitial change is always present. In 
some areas there are found numerous cells infiltrated, there 
being some leukocytes, many round cells, and occasionally 
red blood-cells ; edema is also noted in the interstitial process. 
The Malpighian bodies share in the pathologic change ; in 
many cases the epithelial cells become granular, fatty, and 
desquamated. Between the blood-vessels making up the tuft 
there is an albuminous exudation which presses upon them. 
Bowman's capsule is often thickened. The interstitial change 
in chronic parenchymatous nephritis is never diffuse, but 
scattered through various portions of the substance. 

Pathology of Large White Kidney. — This is the rarest of 
the various forms of chronic nephritis. Amyloid disease of 
the kidney resembles the large white kidney. An error may 
arise in differentiating between the gross appearance of these 
two conditions, which is somewhat similar ; however, micro- 
scopic and chemic tests prove their individuality. This kidney 
is markedly enlarged ; the fibrous capsule strips readily, leaving 
a smooth surface beneath. The substance of the kidney is 
found to be somewhat doughy, cutting quite easily. Its color 
is yellowish-white, streaked with grayish-red areas, the pyra- 



564 DISEASES OF THE KIDNEYS. 

mids being somewhat darker than the surrounding tissue, and 
well defined. There is an increase in the width of the cortical 
portion. Microscopic examination reveals marked fatty and 
granular degeneration of the epithelial cells of the glomeruli 
and remaining portions of the tubule, the lumina of the tubules 
in many places being filled with the desquamated epithelial 
cells. The interstitial portion in some parts reveals inflam- 
matory change, polynuclear leukocytes, red blood-cells, and 
numerous round cells appearing in scattered areas. The 
marked fatty degeneration and anemia give the kidney its 
characteristic color and cause its loss of consistency. 

Pathology of Chronic Hemorrhagic Kidney. — The gross 
appearance of this variety of chronic nephritis closely resembles 
acute diffuse nephritis ; it differs, however, in the fact that the 
kidney is very tough. It is somewhat mottled, there being 
areas of dark-red and of purplish color intermingling, thus 
causing the mottled appearance. The capsule begins to show 
adherence to the kidney substance at various points. The 
cortical portion is also increased in width, but here and there 
shows contraction, due to the interstitial alteration. This form 
of nephritis shows more marked interstitial change than the 
large white kidney, also areas of hemorrhage intermingled with 
the other characteristics of chronic parenchymatous nephritis. 
The form previously described is often with difficulty differen- 
tiated from this variety, as the interstitial changes appear in 
both. The cicatricial tissue may be so marked as to cause 
atrophy of some of the glomeruli and uriniferous tubules. 

Pathology of the Mottled or Secondary Cirrhotic Kidney. — 
As the process continues, and connective tissue increases, con- 
traction results, so that the kidney now becomes of about nor- 
mal size. The fibrous capsule becomes thickened at points and 
quite firmly adherent to the kidney substance, the surface of 
the organ being slightly irregular and mottled, the darker areas 
being due to the interstitial change and the lighter ones to the 
fatty and anemic changes which have previously been described. 
The organ is quite tough, and narrowing of the cortex be- 
comes apparent at many parts. The cut surface is streaked 
or mottled. This form of nephritis is quite common, the inter- 
stitial and parenchymatous changes proceeding hand in hand. 
It closely resembles the kidney of chronic interstitial nephritis, 
and may be said to form the bridge between chronic paren- 
chymatous and chronic interstitial nephritis. From the clinical 
standpoint, it is known that cessation or abatement of the 



CHRONIC DIFFUSE PARENCHYMATOUS NEPHRITIS. 565 

symptoms may occur in this variety. However, the destroyed 
epithelium, which has been replaced by fibrous connective 
tissue, never regains its normal condition. 

General edema and dropsy of the serous cavities is noted 
in all three of the chronic forms of parenchymatous nephritis ; 
however, hypertrophy of the left ventricle of the heart is most 
pronounced in the form last described (secondary cirrhotic 
kidney). Upon postmortem examination, edema is found in 
many organs, such as the brain and membranes, but there is 
edema particularly of the lungs. Sclerotic arterial changes 
are especially likely to occur with the mottled or secondary 
cirrhotic kidney. 

Symptoms of Large White Kidney. — This is a form de- 
veloped from the acute variety, in those in whom the disease 
has existed for months, and in whom chronic parenchymatous 
changes have formed. The urine, which was scanty and high- 
colored, becomes more copious, often quite abundant in 
amount. The albuminuria, dropsy, and anemia, which have 
never entirely disappeared, become more prominent again, 
and often resist treatment. The characteristic renal fades is 
present. There is marked edema of the feet. The urine is of 
high specific gravity, and loaded with albumin, twenty grams 
often being passed in twenty-four hours. Many of the symp- 
toms encountered in the acute form may occur in this variety. 

Symptoms of Hemorrhagic Kidney. — The symptoms are 
similar to those just described, the obstinate dropsy and the 
hemorrhagic urine being most characteristic. The urine may 
even increase to the normal amount, yet the dropsy does not 
entirely disappear. There is slight hypertrophy of the left 
ventricle, and there may be changes in the walls of the vessels. 
By some writers (Rosenstein and Aufrecht) it is believed that 
this is a separate form of renal disease ; most observers hold 
that it is an acute exacerbation of the chronic variety. It is, 
however, a very rare form of chronic renal disease. 

Symptoms of the Mottled or Cirrhotic Kidney. — In this 
variety the disease is chronic from the onset. The first symp- 
tom noted is the dropsy, which, as a rule, is moderate at 
first, appearing particularly in the eyelids and at the ankles. 
There is marked anemia, the patient complaining of fatigue, 
dyspnea, headache, and palpitation upon slight exertion. This 
variety, under appropriate treatment, may apparently recover ; 
relapses, however, are frequent, the disease continuing for 
years, until finally some complication closes the scene. 



566 



DISEASES OF THE KIDNEYS. 



CHEMIC AND MICROSCOPIC CONDITION OF THE URINE IN 
TYPICAL CASES OF THE THREE VARIETIES OF KIDNEYS 
SEEN IN CHRONIC DIFFUSE PARENCHYMATOUS NEPHRITIS. 

Chemic. 



Urine. 


Large White 
Kidney. 


Mottled or 
Secondary Cirrho- 
tic Kidney. 


Chronic Hemor- 
rhagic Kidney. 


Amount 


Diminished consider- 
ably. 


Normal or above. 


Diminished. 


Color 


Yellow ; yellowish-red. 


Light yellow ; turbid. 


Reddish-yellow. 


Specific gravity . . 


Above normal. 


Normal or below. 


Above normal. 


Reaction 


Acid. 


Acid. 


Acid. 


Sediment 


Present ; often abund- 
ant. 


Present. 


Present. 


Urea 


Diminished. 


Diminished. 


Diminished. 


Albumin 


Abundant, T V to 1$ or 
more. 


Less than large white 
kidney. 


Abundant. 



Microscopic. 



Crystals 


Urates. 


Rarely found. 


Rare. 


Casts 


Granular, hyaline, and 
fatty casts. 


Granular and hyaline 
casts especially. 


Granular, hyaline, 
and sometimes 
blood-casts. 


Cells 


Degenerated epithelial 
cells, especially fat- 
ty ; leukocytes. 


Degenerated epithelial 
cells ; leukocytes ; 
rarely red blood-cor- 
puscles. 


Epithelial cells, red 
blood - corpuscles, 
and leukocytes. 



The Urine. — The specific gravity varies from 1015 to 1040. 
It is light yellow in color, often cloudy, and acid in reaction. 
The amount of albumin contained in the urine is large, from 
1 % to 5^, more albumin being passed after exercise than 
after rest. The urea is diminished in amount. Microscopic 
examination reveals granular large and small hyaline casts, and 
occasionally epithelial and fatty casts. There are also observed 
granular debris, leukocytes, and degenerated epithelial cells. 

Dropsy. — This is a most constant symptom, affecting the 
face, the extremities, the scrotum, and the serous cavities. 

Gastric Symptoms. — These are common. Nausea and 
vomiting often occur, the appetite is lost, the tongue is coated, 
and there is constipation alternating with diarrhea. 

Blood.— An anemia of the chlorotic type often occurs. The 



CHRONIC DIFFUSE PARENCHYMATOUS NEPHRITIS. 567 

erythrocytes may be diminished to 800,000 per cubic milli- 
meter. The tendency to hemorrhage is marked. 

Changes in the Circulatory System. — Some changes take 
place in the heart, such as hypertrophy with dilatation, espe- 
cially with the secondary cirrhotic kidney. The second aortic 
sound is often accentuated, and hemic murmurs may be heard 
over the base of the heart. 

Eye Symptoms. — Often there is dimness of vision, and 
specks and mists float before the eyes. Albuminuric retinitis 
occurs, but is not so common as in chronic interstitial nephritis. 

Complications. — Pleurisy, pneumonia, pericarditis, menin- 
gitis, erysipelas, gangrene of the skin, and edema of the lungs 
are of common occurrence. If cardiac hypertrophy becomes 
marked, apoplexy is liable to result. Uremic phenomena are 
frequent. 

Differential Diagnosis. 1 — 

Chronic Hemorrhagic Mottled or Secondary 

Large White Kidney. Kidney. Cirrhotic Kidney. 

Edema extensive and Edema excessive and ob- Edema varies, often 

tenacious; anemia stinate; anemia nearly disapp ear s ; 

marked. marked. anemia marked. 

Heart shows no hyper- Heart slightly hypertro- Heart hypertrophied ; 

trophy. phied. often dilated. 

Urine of highest specific Urine has abundant al- Albumin in urine varies ; 

gravity ; largest amount bumin ; red corpuscles the specific gravity is 

of albumin ; micro- in largfe amount and lower ; casts often dis- 

scopic elements show constant. appear, 
fatty changes. 

Prognosis. — Complete recovery is extremely rare. The 
disease may be delayed for years, but even the mildest cases 
may terminate in uremia. The great liability to complications 
should always be borne in mind. 

Treatment. — The patient should be protected by warm 
clothing, flannels being worn during the entire year. If pos- 
sible, the patient should live in a warm, dry climate, remaining 
in the sun the greater part of the day. The functions of the 
skin must be maintained. Warm baths followed by friction 
and rubbing of the skin are useful. The diet is most important, 
milk being the best food. Kumiss and buttermilk may also 
be given, or milk and Vichy water. In mild cases the follow- 
ing articles may be allowed sparingly : Fish, white meats 
(such as veal and white meat of chicken), green vegetables, 
and small quantities of bread. Alcohol and malt liquors 

1 Modified from Loomis-Thompson, "American System of Practical Medi- 
cine." 



568 DISEASES OF THE KIDNEYS. 

should be strictly prohibited. Water must be taken in large 
amounts. Tobacco, if used at all, should be indulged in 
sparingly. Moderate exercise, avoiding fatigue, is of advan- 
tage. Bicycling is to be strictly forbidden. 

The functions of the body require careful attention. Con- 
stipation can best be treated by the administration of broken 
doses of calomel from time to time, followed by a saline. 
When the amount of urine has been markedly decreased, the 
use of digitalis is found beneficial, as is also Basham's mixture. 
One-drop doses of the tincture of cantharides three times a 
day in Basham's mixture will be found of advantage when the 
amount of the urine has become small. Complications must 
be treated upon general principles. 

CHRONIC INTERSTITIAL NEPHRITIS. 

Synonyms. — Chronic contracted kidney ; granular kidney ; 
cirrhosis of the kidney ; gouty kidney ; small red kidney. 

Etiology. — The disease occurs most frequently in males 
between the ages of forty and sixty. It arises particularly in 
the lithemic or gouty diathesis, and in those subjects who 
early show a tendency to fibroid changes in the arterial system. 
Alcohol is one of the principal predisposing causes. Partaking 
of rich food, with very little exercise, is also a causative factor. 
Gout and syphilis are important causes. 

Pathology. — In this form of nephritis the kidney is usually 
markedly reduced in size, sometimes weighing as little as fifty 
grams ; however, when this change occurs, both kidneys are 
not liable to be affected to the same extent. When the kidney is 
very small, the perirenal fat is often extensive. If the process be 
of short duration or of slow development, it may be of almost 
normal size, so that in a measure it may quite closely resemble 
the secondary cirrhotic kidney. The surface of the organ 
becomes granular, this varying from a finely granular to a 
somewhat hobnail appearance. The fibrous capsule is drawn 
down in many points, giving rise to a granular appearance, 
is firmly adherent to the kidney substance, and anastomosis 
between the blood-vessels of the cortex and the capsule may 
take place. The color of the surface is reddish or reddish- 
gray, sometimes red -brown, intermingled with lighter reddish - 
yellow areas. Frequently retention cysts are visible under the 
fibrous capsule, which vary in size from a pinhead to a pea, 
or occasionally they may be larger. These are filled with 



Plate VIII. 




1 




$Mm 




I. Acute hemorrhagic nephritis. 
II. Chronic parenchymatous nephritis. 
HI. Chronic interstitial nephritis. (From 
Therapie der Nierenkrankheiten.") 



Rosenstein, " Pathol ome und 



CHRONIC INTERSTITIAL NEPHRITIS. 569 

a clear fluid, rarely turbid or purulent. The kidney appears 
tough, and upon section the knife meets with much resist- 
ance (leathery consistency). On viewing the cut surface it 
will be found that the entire width of the kidney is de- 
creased, but the cortical portion suffers most, so that it is 
narrowed, and occasionally forms but a faint rim. The marked 
narrowing of this part of the kidney is due to the fact that it 
is the most delicate, while the medullary portion contains a 
stronger supporting structure, so that when the newly formed 
connective tissue in the cortex contracts, the cortex suffers 
most. The pelvis of the kidney occasionally may be larger 
than normal on account of the contraction of the organ, 
but it is always so on account of the disproportion in size. 
In chronic nephritis due to gout and. lead-poisoning it not 
infrequently happens that infarcts are found that contain uric 
acid deposits or calcareous infiltration. -Microscopic exam- 
ination reveals the interstitial change as being more marked 
at certain points, but particularly localized in the cortex. 
The fibrous connective tissue is found to separate many of 
the tubules, and there also appears here and there marked 
cellular infiltration of round cells and leukocytes. The epi- 
thelial cells lining the tubules show granular and fatty degen- 
eration in limited areas, but the greater number of the epi- 
thelial cells appear normal, and in stained preparations the 
nucleus of these cells has its normal selective power for the 
basic stains. The epithelial cells of the Malpighian bodies 
may also show similar changes. As the new-formed fibrous 
tissue contracts, some of the tubules and glomeruli atrophy, 
many of them being completely replaced by areas (or whorls) of 
sclerotic tissue. When the contraction takes place around the 
tubule at some distance from the Malpighian body, and blocks 
up the lumen, a cyst forms, which has previously been described, 
and this appears under the microscope as a large space. The 
arteries are also thickened, the intima, the media, or the adven- 
titia showing sclerotic changes ; and often the outer coat is 
continuous with the surrounding new-formed fibrous tissue. 
It will also be noted that in some areas the glomeruli and 
tubules are hypertrophied, they being larger than normal, and 
the lumina of the tubules being well marked. The veins rarely 
show any change, but occasionally the outer coat is thickened. 
From the narrowing of the lumina of the arteries anastomotic 
changes arise. The heart in this form of nephritis shows 
marked hypertrophy ; this in the greater number of cases is 



570 DISEASES OF THE KIDNEYS. 

chiefly limited to the left ventricle, but may involve the entire 
organ. It is also frequently associated with dilatation. Arterio- 
sclerosis of many of the blood-vessels of the body frequently 
causes chronic interstitial nephritis. Congenital narrowing of' 
the aorta in young chlorotic individuals has been noted, which 
subsequently gives rise to chronic contracted kidney. A con- 
tracted kidney is found on the postmortem table which 
during life may not have given rise to characteristic symp- 
toms. 

Symptoms. — The symptoms may be so ill defined as to 
escape detection. As a rule, muscular weakness and lassitude 
develop. There is gradual loss of appetite, dyspepsia some- 
times appearing. Headache, pain in the neck and back, 
irritability of temper, loss of memory, and sleeplessness are 
all early symptoms. The amount of urine is greatly increased, 
from 3000 to 6000 c.c. being passed in a day ; it is clear, acid 
in reaction, and of a pale, slightly greenish color. The specific 
gravity is low — from 1004 to 1012. Albumin, if present at 
all, is found in very small amounts ; it may be absent alto- 
gether. The amount of urea eliminated is diminished. Some 
few hyaline casts may be discovered upon microscopic exam- 
ination. The important characteristic symptoms relate to the 
circulatory system, consisting of marked hypertrophy of the 
left ventricle. The arterial tension is increased. The pulse is 
firm. There is an accentuated ringing sound at the aortic 
cartilage ; the apex-beat is forcible and heaving. As long 
as compensation is maintained no symptoms are developed ; 
however, dilatation and cardiac insufficiency soon arise. 
There is shortness of breath upon slight exertion, and palpi- 
tation, and gradually the symptoms of edema of the lungs 
appear. The patient is pale, and the eyelids may be slightly 
swollen. The skin* of the body is dry, there being but slight 
tendency to sweating. Marked anemia of the chlorotic type 
is present. Edema, as a rule, is absent; when it occurs, it is 
due to secondary parenchymatous changes or failure of com- 
pensation. The eye symptoms are important, albuminuric 
retinitis being common in this condition. 

Complications. — Cerebral hemorrhage is a frequent com- 
plication. Inflammation of the serous membranes is common. 
Peritonitis, pericarditis, pleurisy, pleurisy with effusion, chronic 
pericarditis, bronchopneumonia, lobar pneumonia, neuro- 
retinitis and retinal hemorrhages, and edema of the glottis are 
all complications. 



AMYLOID DISEASE OF THE KIDNEY. 5/1 

Prognosis. — When the disease has once become established, 
there is no likelihood of a cure. The patient may live for a 
number of years, the average duration of life being from three 
to five years. 

Treatment. — The treatment in regard to general hygiene, 
diet, and so on, is the same as in other forms of renal disease. 
Diuretics are not indicated. Iodid of potassium is a valuable 
drug, continued for weeks at a time. For the palpitation and 
cardiac difficulty nitroglycerin is of use. Complications must 
be treated as they arise. 

AMYLOID DISEASE OF THE KIDNEY* 

This is a disease of the kidney often associated with chronic 
parenchymatous nephritis ; it may, however, exist indepen- 
dently. When it is present, other organs besides the kidney 
are frequently affected. 

Etiology. — The condition occurs most often in cachectic 
individuals. It may arise at any period of life, but most fre- 
quently between the ages of twenty and thirty, and it is found 
in both sexes. Pulmonary tuberculosis, empyema, bronchi- 
ectasis, abscess formations of various tissues, especially of bone, 
chronic malaria, and syphilis are all predisposing causes. 

Pathology. — The organ is usually increased in size, some- 
times being twice that of the normal kidney, and closely re- 
sembling the large white kidney. The fibrous capsule strips 
quite readily, the kidney being of a dull yellow color. It is 
of a tough, bacony consistency. On section, the cortical por- 
tion is increased in width, the Malpighian bodies often stand- 
ing out prominently as small, white, glistening points. When 
treated with Lugol's solution, the characteristic amyloid 
reaction is obtained, the Malpighian bodies and the blood- 
vessels particularly being stained a mahogany brown, while 
the surrounding kidney structure is a light yellow. The 
reaction is better illustrated with some of the anilin dyes. 
(For Amyloid Reaction, see p. 520.) Cirrhotic changes 
not infrequently are found associated with this condition. The 
organ, under such circumstances, is of about normal size, 
very tough, and upon microscopic examination reveals the 
increased fibrous connective tissue. Parenchymatous changes 
are also associated. 

Symptoms. — The disease is always preceded by some 
chronic process, very frequently a suppurative one. The 



572 DISEASES OF THE KIDNEYS. 

patient becomes weaker, and dyspnea is more marked, being 
increased upon exertion ; he becomes very pale, and the com- 
plexion has a waxy cast. The urine passed is increased in 
quantity, micturition being more frequent, the patient being 
compelled to get up at night and pass urine. Upon examina- 
tion of the abdomen, the liver and spleen are found to be 
enlarged. An examination of the urine shows that it is light 
in color, often straw-colored, and is of low specific gravity — 
1005 to 10 1 5. In the scanty sediment are found large hyaline, 
small granular, and broad waxy casts, with fatty globules 
adhering to them. Besides these there are found microscopic- 
ally leukocytes and fatty epithelium. Albumin is almost 
always present ; exceedingly rarely is it absent. The amount 
of urea excreted is below normal. Dropsy is usually present, 
and it often shows itself as anasarca, the subcutaneous tissues 
and serous cavities being infiltrated. The edema, when once 
it appears, is persistent. The gastric disturbances consist in 
nausea, anorexia, severe vomiting, and diarrhea. Among the 
circulatory symptoms, hypertrophy of the heart is found to be 
absent. Only in rare instances do changes in the heart-wall 
occur. The temperature, as a rule, is normal. 

Prognosis. — The prognosis is unfavorable, the duration of 
the disease being variable. 

Treatment. — General tonic treatment by arsenic, iron, iodid 
of potassium, and cod-liver oil are of use. The same hygienic 
regulations, diet, and exercise should be insisted upon as in 
other forms of renal disease. 



SUPPURATIVE NEPHRITIS. 

Synonyms. — Abscess of the kidney ; acute interstitial ne- 
phritis. 

This disease was known to Hippocrates, and Galen and 
many of the oldest authors have described it. 

Etiology. — This condition is clinically always of bacterio- 
logic origin. It may be due to chemic substances which in- 
duce suppuration. Experimentally it is known that turpentine 
may produce suppuration. The most important micro-organ- 
isms which have been found as causative factors are the sta- 
phylococcus pyogenes aureus, the streptococcus pyogenes, 
more rarely the bacterium coli communis, also the gonococcus, 
the tubercle bacillus, the diplococcus of pneumonia, the bacil- 
lus typhosus, and the ray fungus. There are four ways in 



SUPPURATIVE NEPHRITIS. 573 

which the organism may reach the kidney : (i) Externally 
through a perforation (trauma) ; (2) from infection by exten- 
sion through the perirenal tissues ; (3) from the urinary pas- 
sages, traveling upward to the kidneys through the urethra, 
bladder, prostate, and ureters ; (4) through the blood, as in 
pyemia. The cases arising from trauma occur particularly 
in young individuals.. Those arising from the second cause 
are most common in the female sex, in which perimetritis plays 
the chief role. The third arises most frequently in the male 
sex, after the fortieth year ; and under the fourth heading, the 
affection occurs at any age, and may be met with in the new- 
born. 

Pathology. — When resulting from trauma, the suppurative 
process may be slight, or it may be so extensive as to involve 
the whole organ, which exists as a pus sac. 

Pus may find its way through the ureters into the bladder, 
or through a fistula to the external part of the body, or to 
other organs, such as the bowel, peritoneum, liver, bronchi, 
or the lung structure itself; and, lastly, pyemia may follow. 
When arising by contiguity and continuity of structure, the 
picture is similar to that just described ; except that the kid- 
ney substance is not excoriated, as is so frequently the case, 
and also that hemorrhages are not apparent. When the infec- 
tion extends from the urinary passages, they are identical with 
those which will be described under pyelonephritis. When 
the infection is brought to the kidney through the blood chan- 
nels, both organs are involved ; the kidney is somewhat irreg- 
ular in outline, and the surface shows yellowish areas sur- 
rounded by a hemorrhagic zone. When the capsule is 
removed, it is adherent in some parts. On section, numerous 
abscesses are exposed, varying in size from a pinhead to a pea, 
rarely larger. The pus is yellowish or yellowish-red, the 
latter depending upon blood being admixed. Upon micro- 
scopic examination the characteristics of acute inflammation 
leading to suppuration are noted. If the suppuration be 
chronic and long-continued, thickening; bv fibrous tissue is 
frequently noted around the abscess. Sometimes it is found 
that cicatricial tissue has replaced a small abscess. This is 
most likely to occur from traumatic influences. Compensatory 
hyperemia of the healthy portion of the organ or of its fellow 
upon the opposite side is common. In the pyemic variety 
these changes are not always observed, as the process is very 
rapid. 



574 DISEASES OF THE KIDNEYS. 

Symptoms. — Abscesses of the kidney may exist without 
giving rise to characteristic symptoms, or the symptoms are 
masked by those of the primary disease. The most characteris- 
tic symptoms occur in the traumatic variety, in which the remains 
of the injury may be seen in the renal region, also tenderness 
upon pressure. Symptoms of shock, and either hematuria 
or anuria, chills which may be repeated, followed by fever, 
may occur at the onset, or may occur in a few days, when 
abscess formation has taken place. If the subsequent course 
of the injury has not been severe enough to cause death, it 
may be that the pus has emptied itself through the pelvis of 
the kidney and has been discharged with the urine. In such 
cases the fever declines day by day until the discharge of pus 
has ceased entirely. The pus may find an artificial opening, 
forming a fistulous tract either internally or externally. If 
this latter condition arise, the fever is apt to be prolonged and 
of a pyemic character unless the pus should find its way into 
the peritoneal cavity or erode a large blood-vessel, leading to 
speedy death. 

In cases in which abscesses of the kidney have occurred 
from continuity of structure, the symptoms are less marked. 
There may be fever, pain in the abdomen and back, and diffi- 
culty in urination. A tumor may be found in the renal re- 
gion, which is painful upon palpation. The appearance of 
pus in the urine in such cases does not necessarily point 
to abscess of the kidney, as the pus may have found its 
way into the urinary passages without affecting the kidney. 
Only in those cases in which, with the appearance of pus 
in the urine, a tumor in the renal region has diminished 
in size or entirely disappeared, is a diagnosis of renal abscess 
permissible. The further progress of the affection is the 
same as in the traumatic variety, except that the progno- 
sis is not so apt to be favorable. In both forms the urine may 
appear perfectly normal as regards the quantity, color, etc. 
Especially is this the case when only one kidney is affected. 
Occasionally, however, the urine shows marked changes, par- 
ticularly in cases in which both kidneys are affected by a 
purulent process. In such cases the quantity of urine is 
usually normal. The reaction is acid, or, from the. presence 
of considerable quantities of pus, it may be either neutral 
or even alkaline, and its appearance turbid, and the de- 
composing purulent material in the urine is apt to be am- 
moniacal. Albumin, as a rule, is present only in small 



SUPPURATIVE NEPHRITIS. 575 

amounts, except where the purulent process may have pro- 
duced a parenchymatous nephritis. In such cases the urine 
will show all the characteristics of parenchymatous nephritis, 
large quantities of albumin, and various forms of tube casts. 
Occasionally, small particles of kidney substance, which have 
become loosened in the purulent process, may be passed with 
the urine. When the amount of urine has been markedly 
diminished, the danger of uremia must be thought of, al- 
though this is an exceedingly rare sequence of suppurative 
nephritis. 

The symptoms due to suppurative nephritis occurring from 
infection of the urinary passages will be mentioned under 
pyelonephritis. The symptoms of suppurative nephritis due 
to pyemic and septopyemic conditions are those of the general 
process, and are not particularly referable to the kidney. 
There may be marked changes in the urine. If large num- 
bers of micro-organisms be found in the urine, or anuria 
occur, this condition must be suspected. 

Diagnosis. — Suppurative nephritis due to pyemic condi- 
tions can not be diagnosticated with certainty ; it should be 
suspected when in the course of the pyemic process albumin- 
uria and pus in the urine suddenly show themselves without 
the symptoms of parenchymatous nephritis. The conditions 
which are most important in leading to a diagnosis are a pre- 
ceding history of trauma or of a source of infection, and the 
symptoms which particularly point to this condition are pain 
in the renal region, fever of the pyemic type, enlargement or 
tumor in the region of a kidney, and the presence of pus in 
the urine. Of all these symptoms, tlie appearance of a tumor 
in the renal region is the most important. 

Prognosis. — The primary traumatic cases give a more 
favorable prognosis than the other varieties of suppurative 
nephritis. In the pyemic form the prognosis is necessarily 
unfavorable. 

Treatment. — If pus can positively be diagnosticated in the 
kidney the indication to release the pus or entirely to remove 
the kidney becomes imperative ; which method is more likely 
to be successful, must be left to the judgment of a competent 
surgeon. If for any reason removal of the pus is not prac- 
ticable, the condition must be treated symptomatically. The 
pain should be lessened, attempts should be made to reduce the 
fever, and the general constitution of the patient maintained 
by a concentrated nutritious liquid diet, stimulants, and tonics. 



57^ DISEASES OF THE KIDNEYS. 



PERINEPHRITIC ABSCESS. 

This condition may arise from suppurative diseases of the 
spine, the pus finding its way into the tissues surrounding the 
kidney. Infection may also arise from suppuration of the 
bowel, not uncommonly from disease of the vermiform ap- 
pendix, from abscess of the liver, from an empyema, and, lastly, 
from abscess of the kidney itself. 

Symptoms. — Pain in the lumbar region, of a dull, aching 
character, and occasionally referred to the hip-joint or thigh, 
is a prominent symptom. The thigh of the affected side is 
partially flexed, and the testicle may be retracted. Upon 
examination it will be found that the pain is aggravated upon 
pressure. There may be bulging of the loin, and occasionally 
edema and fluctuation are noticed in this region. A large 
tumor is sometimes distinctly palpable. Fever of a septic 
type is usually encountered. 

Treatment. — The treatment is surgical. Early evacuation 
of the pus is indicated. Tonics and stimulants are necessary 
to support the patient. 



FATTY DEGENERATION AND FATTY INFILTRA- 
TION OF THE KIDNEY. 

It is improbable that fatty infiltration ever occurs in- the 
kidney in the human subject ; however, fat is sometimes elim- 
inated, and passes through the vessels of the glomeruli into the 
tubules. Fatty degeneration of the kidney, affecting the epi- 
thelial cells, is so constant a feature of chronic parenchyma- 
tous nephritis that it might be considered with that condition ; 
it results from severe anemia, particularly progressive perni- 
cious anemia, and horn the administration of phosphorus, arse- 
nic, antimonium, cantharides, chloroform, carbon dioxid, 
chromic acid, aloin, and iodoform ; and, also, some one of 
the infectious processes may give rise to this condition. 

PYELITIS AND PYELONEPHRITIS. 

Etiology. — The most frequent cause of this disease is 
mechanical irritation from foreign bodies, particularly renal 
calculi, the stone often being sharp, causing destruction of the 
mucous membrane ; however, finer calculi (gravel) may also 



PYELITIS AND PYELONEPHRITIS. 577 

produce mechanical irritation. This condition results more 
rarely from tumors, such as carcinoma and tubercle, rarely also 
from parasites, from extension upward and from a cystitis. 
The micro-organisms that most frequently give rise to this 
condition are the gonococcus and the bacillus coli communis. 
Such irritants as turpentine, cubebs, copaiba, oil of sandal- 
wood, cantharides, and mustard have a special action upon 
the parenchymatous structure of the kidney and the mucous 
membrane of the pelvis, and may give rise to pyelonephritis. 
In a similar way, it may occur in the infectious diseases, 
especially in smallpox, dysentery, typhus, and cholera. It 
may also arise from congestion of the organ, as occurs in val- 
vular heart disease, and from displacement of the kidney, the 
ureter being twisted or pressed upon. The condition may 
arise from trauma, also from cold and exposure, especially 
when this affects the abdomen. Pyelitis sometimes follows 
various inflammatory conditions of the kidney. Inflamma- 
tion of the tissues surrounding the pelvis of the kidney, such 
as a perinephritic abscess, may give rise to pyelitis. It is 
slightly more common in the male than in the female sex, 
and is more frequent in adults and in old age. The con- 
dition is most frequently unilateral ; even when it results 
from cystitis it is more marked on one side than upon the 
other. 

One of the forms of inflammation met with is the acute 
catarrhal. The mucous membrane of the pelvis becomes 
swollen and covered with mucus. The epithelial cells appear 
granular, many being desquamated, and leukocytes and red 
blood-cells frequently are found in large numbers, as well as 
various micro-organisms. In chronic catarrhal inflammation 
the mucous membrane becomes markedly thickened ; the color 
is brownish-red, and the free surface is covered with thick 
mucus, or in some cases with purulent material. Occasionally 
ulceration is noted in the mucosa, and sometimes there are 
cystic formations. The walls of the pelvis may also reveal scler- 
otic changes, so that they become thicker and more resistant. A 
fibrinous exudate may occur upon the mucous membrane from 
severe irritants, such as cantharides, and in the course of infec- 
tious processes, as those of a septic and pyemic nature. When 
this exudate causes obstruction, or if strictures have formed 
in the course of chronic interstitial changes, the flow of the 
urine is hindered ; the pelvis, and the kidney, itself may become 
distended, atrophy of the kidney substance resulting, and the 
37 



578 DISEASES OF THE KIDNEYS. 

organ being transformed into a sac containing either watery or 
purulent material (hydronephrosis or pyonephrosis). If the 
condition be long continued, interstitial changes result in the 
kidney. When the urine is dammed back into the kidney, 
dilatation of the uriniferous tubules results ; the epithelial ceils 
become degenerated, and the fluid may extravasate into the 
interstitial portion, often giving rise to abscesses. These may 
either be small, or, when they unite, form large purulent areas. 
The abscesses may be limited by the formation of new-formed 
connective tissue, and in some instances calcareous infiltration 
results in the capsule. From suppuration of one kidney 
amyloid disease may result in the opposite organ. The 
ureter of the affected side usually shows inflammatory changes 
similar to those described in the pelvis. Compensatory hyper- 
trophy of the unaffected organ, and in some instances hyper- 
trophy of the heart, result. Pyemia sometimes follows. 

Symptoms. — Only that form of pyelonephritis occurring 
acutely and primarily through irritation from calculi and drugs 
gives rise to characteristic symptoms, the most important of 
these being changes in the urine. The urine becomes less- 
ened in amount, contains mucus, pus, and frequently blood, 
and even crystals, especially of uric acid. If a fibrinous 
exudate be present, small masses of fibrin may be found in 
the urine. The microscope will show blood, pus corpuscles, 
pelvic epithelium, crystals of uric acid, oxalates, masses of 
fibrin, and occasionally parasites. 

Frequent urination is an important symptom. Occasion- 
ally, even if one kidney be entirely healthy, anuria may occur, 
this probably being due to reflex action. In chronic pyelitis 
the urine is rarely diminished ; on the contrary, an increased 
quantity, amounting to two or even three times the normal, 
is voided. The specific gravity is normal, the reaction acid, 
and only in cases in which large quantities of pus are pres- 
ent will it be neutral or alkaline ; it is then apt to be turbid in 
appearance, owing to the intermingling of mucus or pus. A 
change in the character of the urine voided is apt to occur in 
the course of chronic pyelitis, especially if the flow of the 
urine from the diseased kidney be hindered by a calculus, by 
clotted blood, or by a plug of mucus, so that the urine com- 
ing from the sound kidney will appear clear and perfectly" 
normal. Pain in the renal region is a common symptom of 
acute pyelitis. As a rule, this is present in chronic pyelitis. En- 
largement of the kidney may take place, as has been indicated 



HYDRONEPHROSIS. 579 

in the pathology, from a hydronephrosis or a pyonephrosis. 
Some degree of fever is always present in acute pyelitis ; it is 
moderate in height, and must not be confounded with the so- 
called urethral fever, which is usually remittent or intermittent 
in character. 

Prognosis. — In acute pyelitis the prognosis is favorable in 
the main, especially if it be due to renal calculi, or to such irri- 
tants as cantharides, or to one of the infectious fevers, in which 
the etiologic factor is apt to subside. In chronic pyelitis, or in 
cases in which suppuration of the kidney develops, the prog- 
nosis is not so favorable, this being especially true if accom- 
panied by amyloid disease. 

Treatment. — The patient must lie quietly in bed, protected 
from cold. The patient should be given a bland diet and 
alkaline mineral waters. Free application of heat to the renal 
region may be used. Warm baths are grateful to the patient. 
When pain occurs, opium in some form, as opium hypoder- 
mically or opium suppositories, is useful. In chronic pyelitis 
astringents are indicated, such as acetate of lead, uva ursi, etc. 
Salol and methylene-blue are sometimes found of benefit. 
Surgical interference is necessary if hydronephrosis or pyelo- 
nephrosis is present. 

HYDRONEPHROSIS. 

Definition. — Obstruction to some part of the ureters, 
bladder, or urethra gives rise to dilatation of the pelves and 
tubules of the kidney, from the accumulation of the urine. 

Etiology. — Twisting of the ureter, as is met with in floating 
kidney, may give rise to the condition, or the ureter may be 
obstructed by an accumulation of parasites. It may be the 
result of congenital narrowing of the ureter or urethra. Pres- 
sure upon the ureter may result from fibrous bands or tumors. 
Calculi, tumors, and strictures may occlude the lumen. En- 
largement of the prostate in many cases gives rise to the ob- 
struction of the ureter. The accumulation of fluid in some in- 
stances causes a very large swelling, which may be mistaken for 
ascites. Compensatory hypertrophy of the opposite organ 
may occur, and hypertrophy of the heart is rarely encoun- 
tered. 

Sometimes, when the obstruction is due to calculi or to the 
twisting of the ureter, an intermittent hydronephrosis is pro- 
duced, the distention occurring paroxysmally. When the en- 



580 DISEASES OF THE KIDNEYS. * 

largement is small, it is often not recognized until the autopsy 
is made. 

Upon examination of the patient, a swelling is met with 
in the renal region, but, as before stated, when extensive, 
or when occurring in the floating kidney or the " horseshoe " 
kidney, it may occur in any part of the abdomen, and so may 
be mistaken for ovarian cyst or ascites. A unilateral is much 
more frequent than a bilateral hydronephrosis. Upon per- 
cussion, flatness is noted over the tumor. The dilatation may 
become so marked as to cause rupture and the discharge of 
the fluid. In some instance's suppuration follows, and when it 
is double, uremia may occur. The urine in intermittent hydro- 
nephrosis naturally varies greatly in amount, so that polyuria 
alternating with oliguria may be present. Pain is not a con- 
stant symptom, and when it occurs, it is slight, often produced 
only by pressure. Slight fever may be met with. The ex- 
amination of the urine shows no characteristic signs of this 
condition except, perhaps, in the amount voided at intervals. 
It may contain numerous pus cells and epithelium. 

Treatment. — In some instances massage may be practised 
with favorable results, but the manceuver must always be per- 
formed with great care. If hydronephrosis be due to the float- 
ing kidney, a pad and a binder properly applied are often of 
great benefit. Aspiration and drainage are sometimes necessary. 

TUMORS OF THE KIDNEY. 

BENIGN TUMORS. 
Fibroma, lipoma, angioma, lymphoma, which are met with 
in leukemia, occur ; and, according to Rayer, osteoma and 
chondroma rarely are found. On account of small size, benign 
tumors do not give rise to symptoms. Adenomata occur in in- 
terstitial nephritis ; they are usually from the size of a pea to 
that of a walnut. They are sometimes congenital. Adenomata 
sometimes occur with carcinomata (adenocarcinoma). 

MALIGNANT TUMORS OF THE KIDNEY. 
Carcinoma of the Kidney. — This tumor may be met with 
as a primary or secondary growth. Of all malignant tumors, 
it occurs in this organ in only about 2^ of the cases, including 
both primary and secondary growths. It is a remarkable fact 
that carcinoma of the kidney is relatively more frequent in 
the young than at the age when malignant disease usually 



TUMORS OF THE KIDNEY. 58 1 

occurs. It is more common in males than in females. Trauma 
seems to predispose. 

Of the primary carcinomata, the encephaloid variety is 
more common than the scirrhous form. It may affect one or 
both organs, and seems to be more frequent in the right than 
in the left kidney. The tumor is commonly of large size, so 
that in adults it has been found to weigh fifty pounds. When 
the tumor is secondary, it is nearly always bilateral, and in- 
volves almost exclusively the cortical portion, exceedingly 
rarely the medullary. The tumors vary in size from a pea to 
a walnut, and resemble the primary growth. 

Symptoms. — Primary carcinoma in its onset produces few 
or no symptoms, so that the nature of the affection can 
scarcely be suspected. The characteristic symptoms consist 
of pain in the renal region, hematuria, enlargement of the 
kidney, and cachexia ; however, no particular one of these 
symptoms is constant. Pain is commonly an early symptom, 
and lasts throughout the course of the disease. As a rule, it 
is localized in the renal region, but it may radiate ; occasion- 
ally it shows itself as a severe neuralgia, or it may be colic-like. 
Hematuria may arise at any time in the course of the affection ; 
usually, however, it is one of the earlier symptoms. This 
form is not accompanied by pain. Enlargement in the renal 
region is the most constant of all symptoms ; the growth may 
produce a tumor which is readily palpable, the size varying in 
individual cases. As a rule, however, a large-sized tumor is 
formed in the affected area. If pressure occurs upon the veins, 
varices and edema of the lower extremities may take place ; if 
the portal vein be pressed upon, ascites occurs. The adjacent 
lymphatic glands are enlarged, especially in the secondary 
variety. Cachexia and emaciation are present sooner or later 
in the course of the affection. Disturbance of digestion, 
especially diarrhea, and nervous symptoms, which may often 
be uremic in nature, or due to autointoxication, develop. 
Fever, when not due to complication, shows itself toward 
the close of the affection. In some cases death occurs from 
collapse, with subnormal temperature. The duration of the 
disease is from a few months to a year or more. In children 
the course of the affection is shorter. 

Prognosis. — The prognosis is grave. 

Sarcoma of the Kidney. — Primary sarcoma is less frequent 
than carcinoma, and also particularly met with in childhood, 
but may occur at any age, even in the new-born. It occurs 



582 DISEASES OF THE KIDNEYS. 

more often in females than in males, the left organ being more 
frequently involved. Two-thirds of all the cases have occurred 
in the first ten years of life. The following varieties have 
been met with : Primary and secondary sarcomata, round-cell 
and spindle-cell sarcomata, fibrosarcomata, myosarcomata, 
angiosarcomata, melanosarcomata, and adenosarcomata. Sar- 
coma of the kidney is commonly a soft tumor. 

Symptoms. — Sarcoma can not be clinically differentiated 
from carcinoma, as the symptoms are practically the same. 
The point of differentiation between primary sarcoma and 
primary carcinoma might consist in the fact that sarcomata 
are somewhat more frequent in children than are carcinomata ; 
and glandular enlargement is common in carcinomata. 

Prognosis. — The prognosis is grave. 

Treatment. — The treatment is surgical. 

CYSTS OF THE KIDNEY. 

These may be congenital or acquired, unilateral or bilateral, 
varying from a very small cystic mass to large cysts. The 
most frequent variety are those of small size met with in chronic 
interstitial nephritis. The formation of these has been described 
in the pathology of chronic interstitial nephritis. Congenital 
cysts are almost always bilateral, the entire organ frequently 
being composed of cysts. Large ones are sometimes en- 
countered. They are more frequent in men than in women, 
and especially in those beyond middle life. Echinococcus 
cysts sometimes occur in the kidney but are very rare. 

Symptoms. — Cysts may occur without giving rise to any 
symptoms. The symptoms of chronic interstitial nephritis are 
commonly met with. Hematuria may occur. 



MALFORMATION AND MALPOSITION OF THE 
KIDNEY* 

MALFORMATIONS. 

Malformations of the kidney are usually congenital, and 
when acquired are the result of diseased conditions of the 
kidney. The most common forms encountered are the lobu^ 
lated kidneys, supernumerary organs, and fusion of kidneys 
(either by fibrous tissue or by kidney substance), such as the 
" horseshoe " kidney. One or both kidneys may be absent, 
enlarged, or atrophied. 



RENAL CALCULI. 583 



FLOATING KIDNEY. 

Synonyms. — Movable kidney ; palpable kidney ; nephrop- 
tosis. 

The movable kidney occurs more frequently in women than 
in men, it being more often met with in the female sex, on 
account of tight, lacing and also as a result of pregnancy. 
The right organ is more frequently involved. The organ 
may be displaced by tumors pressing upon it or dragging it 
down. Heavy lifting and trauma are also etiologic factors. 
Resorption of the perirenal fat may give rise to the movable 
kidney. It is frequent in neurasthenics. The organ may be 
quite freely movable or very slightly so. Three varieties have 
been described : (i) The palpable kidney, the lower border of 
which can be felt upon deep pressure ; (2) the movable kidney, 
in which the upper edge can be palpated on deep inspiration ; 
and (3) the floating kidney, the organ being so movable as to 
reach above Poupart's ligament or quite freely in the abdomen. 

Symptoms. — These vary greatly : in some instances no 
discomfort is experienced by the patient. The common symp- 
toms are those of a dull dragging pain in the abdomen, 
accompanied by symptoms of neurasthenia or hysteria. Dys- 
peptic symptoms are common. In some instances attacks 
of severe abdominal pain, vomiting, chills, and fever, and 
occasionally collapse are encountered ; they are known as 
Deitl 's crises, and are proved to be due to twisting of the 
renal vessels or to strangulation or compression of the kidney. 
These may be mistaken for renal colic or appendicial colic, 
and also for the crises which occur in tabes dorsalis. When 
this occurs, the organ may be distinctly tender upon pressure ; 
however, in the forms of floating kidney without these par- 
oxysmal attacks the organ is rarely if ever tender upon pres- 
sure. When the ureter is twisted and stenosis results, hydro- 
nephrosis with alternating oliguria and polyuria may develop. 

Treatment. — Great relief is obtained by the proper appli- 
cation of a suitable pad and binder. Operative interference 
consists in fixation of the kidney, and is often necessary. 

RENAL CALCULL 

Synonym. — Nephrolithiasis. 

Under this term are included all -concretions which form out- 
side of the parenchyma of the kidney which have not yet found 



584 DISEASES OF THE KIDNEYS. 

their way into the bladder. According to the size, the smallest 
calculi, which are almost powder-form, are called kidney sand ; 
the larger calculi are called gravel ; and a still larger form is 
known as kidney stone, or renal calculus. These stones are 
principally composed of uric acid, oxalates, and phosphate and 
carbonate of calcium (more rarely magnesia and ammonia), 
and still more rarely of cystin and xanthin, and very exception- 
ally are composed of indigo. 

Etiology. — Renal calculi have been found at all ages ; 
however, they are more common between the thirtieth and the 
sixtieth years of life, and are found during child-life and 
adolescence. Stones forming in the bladder occur more 
frequently early in life, and again after the fiftieth year. The 
affection is much more common in the male than in the 
female. Heredity and family tendency are important etio- 
logic factors, especially in the formation of cystin calculi, 
and to a somewhat less degree in the formation of uric acid 
stones. Uric acid stones are found particularly in families in 
which gout is hereditary. 

Renal calculi are much more common in some localities 
than in others ; however, no locality may be said to be exempt. 
The affection is found most frequently upon the continent 
of Asia. In Africa it is common in Mauritius and Lower 
Egypt. In Europe it is common in Central Russia, in Hol- 
land, in Italy, in Lower Germany, in Hungary, in the eastern 
districts of England, in Scotland, and in parts of France. In 
America it is found particularly in Canada. Its more common 
occurrence in some localities than in others has been attributed 
to climatic influences, particularly the influence of a damp 
climate, in the geologic formation of which lime enters largely 
into the composition of the drinking-water. 

For the production of renal calculi two things are necessary. 
In the first place, a precipitate must form from the urine, and 
a material must be developed which holds this precipitate 
together. This production of sediment is independent of the 
action of the urine. Acid urine never precipitates sulphates 
and phosphates ; on the contrary, uric acid and urates and 
oxalates are precipitated by acid urine. 

The stones vary in size, and, as a rule, the smaller the 
stones, the more numerous they are. The largest one 
that has ever been found weighed 30^ ounces. 1 Stones, 

1 S. Gee, "A Case of Renal Calculi," "Med.-Chir. Transactions," lvii, 

1874. 



RENAL CALCULI. 585 

as a rule, involve only one organ, and are more frequently 
found in the left kidney than in the right. They may be 
found in the kidney tubules, the calyces, the pelvis, or the 
ureter. In the latter position they are usually cylindric ; 
when occurring in the calyces, they are irregular in outline. 
The size and consistency vary, depending upon the position 
of the stone. When they are made up of urates, which are 
the most frequent constituents, they are of a yellowish or 
yellowish-red color, and quite firm, and upon section present 
a concentric appearance. They are dissolved in caustic soda, 
and upon the addition of acetic acid the characteristic " whet- 
stone " crystals are noted. Stones composed of oxalates are 
next in frequency. These stones are much firmer than those 
composed of urates. They are of a grayish or grayish-black 
color, and frequently present a "mulberry" appearance, and 
are usually combined with urates. They are insoluble in 
acetic acid, but are soluble in strong mineral acids. On the 
addition of ammonia the characteristic crystals of oxalates 
are deposited. Calculi composed of phosphates are rarely 
found in the kidney, and are deposited when the urine has an 
alkaline reaction, this condition being met with in pyelitis and 
pyelonephritis. They are soft, chalky stones, of a grayish or 
yellowish color, and are dissolved on the addition of organic 
acids. They frequently contain micro-organisms. Calculi 
composed of carbonates are found less frequently than the 
preceding ones. The calculi composed of cystin, xanthin, 
and indigo are rarely met with, xanthin stones occurring 
particularly in children. The formation of calculi seems to 
depend upon inflammatory conditions of the kidney, such 
as pyelitis, pyelonephritis, parenchymatous and interstitial 
nephritis ; cells, such as desquamated epithelium, frequently 
being the nucleus. When one kidney is involved, the other 
organ often reveals compensatory hypertrophy. Sometimes 
there is hypertrophy of the left ventricle of the heart, or if 
suppurative inflammation involve one organ, the other kidney 
frequently becomes involved and amyloid disease sets in. 

Symptoms. — These depend largely upon the irritation set 
up by the stone and upon the signs attending the attempted 
passage of the calculus. If the stone should lodge in the 
ureter, the symptoms of hydronephrosis or pyonephrosis 
occur. If part of the mucous membrane of the urinary 
passages be injured, hemorrhages and pyelitis result. 

The diagnostic phenomena are those which attend renal 



586 DISEASES OF THE KIDNEYS. 

colic. The calculus may attempt to pass without prodromes. 
It may follow exercise, such as horseback riding ; it may 
follow errors of diet, or the ingestion of alcoholic stimulants, 
and so on. The typical attack begins with sudden, sharp, cut- 
ting, paroxysmal pain in the renal region, which shows a ten- 
dency to radiate, especially toward the bladder, and in the male 
into the testicle of the affected side, which, through the reflex 
action of the cremaster muscle, causes a drawing-up of this 
organ. The pain may radiate toward the inner side of the thigh, 
not infrequently toward the chest and shoulder. The patient, 
in an attempt to relax the muscles, flexes the thighs upon the 
abdomen, and presses the hands against the renal region to 
relieve the agonizing pain. Many reflex symptoms are apt to 
occur. There may be chill, followed by active perspiration, 
frequent desire to micturate, vomiting, and involuntary evacua- 
tion of feces and urine. In the severest cases collapse may 
occur, the pulse becomes small, the extremities grow cold, 
and in rare instances death has occurred. The urine which is 
passed during the attack is small in amount, depending upon 
the grade of stenosis of the ureter and the condition of the 
other kidney ; and not uncommonly there are blood, mucus, 
and pus present. Anuria has been recorded from reflex 
action upon the other kidney. These symptoms may also 
occur if both ureters should be occluded. Anuria, if it 
should last a few days, gives rise to a fatal uremia. 

The duration of an ordinary attack of renal colic is several 
hours, rarely two days. The pain usually ceases abruptly as 
the stone enters the bladder. Hematuria occasionally occurs 
during the course of renal colic. After an attack of renal 
colic there may be a slight aching in the loin, or the pain 
may be dull and remain localized for a long period of time 
if the stone does not pass. If suppuration sets in, the symp- 
toms of pyonephrosis arise. 

Diagnosis. — The diagnosis consists in the characteristic 
pain, its radiation, accompanied by vomiting, chill, fever, 
sweating, and often urinary changes. The stone may be found 
in the urine, and of late years the Roentgen rays have been 
of use in locating the calculus. 

Prognosis. — As a rule, the prognosis is favorable, although 
recurrence is common. 

Treatment. — The treatment consists largely of giving the 
patient relief during an attack of renal colic, which is best 
accomplished by hypodermics of morphin or by the inhala- 



UREMIA. 587 

tion of chloroform. Hot baths, and hot fomentations, such 
as poultices to the loins, are found to be of benefit. The 
patient should partake freely of fluids. During an attack 
of renal colic the diet must be light and carefully regulated. 
The patient should lead a quiet life. The most important 
drugs for the relief of uric acid calculi are piperazin, uro- 
tropin, and salts of lithia. The waters of various mineral 
springs, particularly Carlsbad, Ems, and Kissingen, are valu- 
able in treatment. When the urine is alkaline, urotropin, 
in 15- or 20-grain doses once daily, is of benefit. Surgical 
interference is sometimes necessary. 



UREMIA. 

Definition. — Uremia is a clinical condition due to acute or 
chronic diseases of the kidney or of its conducting apparatus 
(in which stenosis is present). Depending upon whether the 
symptoms arise rapidly and suddenly or whether they are 
more insidious, the condition is known as acute or chronic 
uremia. 

Symptoms. — Sometimes in acute uremia the symptoms 
resemble an epileptic attack, which may be preceded by pro- 
dromes, commonly consisting of headache, spots before the 
eyes, dimness of vision, vertigo, anorexia, nausea and vomiting, 
and occasionally headache, which may be one-sided, resem- 
bling an attack of migraine. Associated symptoms are fre- 
quently tinnitus aurium, which is sooner or later followed by 
complete unconsciousness, coma, with clonic and tonic 
spasms, which may occur in an extremity, in the face, in the 
muscles of the neck, the back, or the abdomen. Rarely are 
these convulsions unilateral. In the course of a few minutes or 
a quarter of an hour the convulsive movements may cease, the 
com? continuing, and Cheyne-Stokes respiration may set in, 
with an increase of the cardiac asthenia. In other instances the 
coma may cease and the patient may promptly recover, or the 
condition known as chronic uremia may develop. During the 
height of the attack the pupils are dilated and do not react to 
light. Cyanosis and relaxation of the sphincter muscles are 
present. The skin is bathed in perspiration ; rarely it is hot and 
dry. The pulse-rate is slowed and shows increased arterial ten- 
sion ; during the convulsive movements it is frequently small 
and intermittent or remittent. If the temperature be taken 
after the convulsive movements, an elevation will be ob- 



588 DISEASES OF THE KIDNEYS. 

served, which soon declines if no new attack occurs. In 
cases that prove rapidly fatal the temperature falls to sub- 
normal ranges. 

The amount of urine is usually markedly diminished, con- 
taining albumin, and, microscopically, casts, renal epithelium, 
and often red and white blood-cells. Eye phenomena are 
very commonly observed, such as amaurosis, which may 
be bilateral, and may be a prodrome of the affection. 
Albuminuric retinitis is frequently observed. 

Chronic Uremia. — All the symptoms which have been de- 
scribed in the acute occur in the chronic variety, with the 
exception that they are milder. A symptom in chronic ure- 
mia is the uriniferous odor, which is often noted by the 
patient. The skin is usually dry and itchy. The tempera- 
ture in chronic uremia, in contrast to the acute form, is always 
normal or subnormal, and if no complications are present, does 
not give rise to fever. Melancholia and delusional insanity 
may follow uremic attacks. 

Uremia may exist for a long period of time — weeks and 
sometimes even months. Under these conditions it may be 
confounded with some of the infectious diseases. 

Diagnosis. — In apoplexy, monoplegia or hemiplegia is 
common, while in uremia they are rarely met with. Alco- 
holic coma is exceedingly difficult to differentiate from uremia, 
as in both conditions subnormal temperature is apt to be 
present, and there is no point of differentiation of the pupil in 
either case. This one point, however, is of importance — con- 
vulsions rarely occur in alcoholic coma, whereas they fre- 
quently occur in uremic coma. Very little stress should be 
laid upon the alcoholic odor of the breath, as it is not at all 
unlikely that the patient may have partaken of alcohol before 
the attack, which, indeed, may have been a factor in producing 
the uremic state. A point of importance lies in the examina- 
tion of the urine. In the coma from opium narcosis the 
pupils are contracted, the pulse is slow and regular, the res- 
pirations are slow and deep, and convulsions do not occur. 

Prognosis. — The prognosis is always grave in uremia ; in 
the acute form extremely so. 

Treatment. — The urine should be withdrawn. In young 
subjects with slow pulse and high arterial tension bleeding is 
indicated, and should be followed by hypodermoclysis of a 
normal salt solution. Intravenous injections of a normal salt 
solution are often indicated. Purging by croton oil and broken 



UREMIA. 589 

doses of calomel is useful. For the convulsions, chloral, 
and morphin hypodermically are the most reliable agents. 
Sweating should be induced by a hot pack or by some similar 
method. The administration of pilocarpin is accompanied by 
danger on account of its depressing effect upon the heart. 



part vi; 

CONSTITUTIONAL DISEASES, 



DIABETES MELLITUS. 

Definition. — A constitutional disease characterized by the 
continuous presence of glucose in the urine. 

Synonyms. — Saccharine diabetes ; glycosuria ; polyuria. 

Etiology. — It occurs at all ages and in both sexes. High 
living is supposed to be a causative factor, but the poor are 
also subject to it. The excessive use of sugar as a food is by 
some supposed to produce the condition. Occasionally the 
disease is hereditary, and may appear in families in which 
insanity, tuberculosis, and gout prevail. It is more common 
among the Jews than in other races. Obesity is supposed to 
favor diabetes. Trauma is an etiologic factor of some impor- 
tance. Shock, nervous depression, and disease of the brain, 
especially of the medulla, are causative factors. It occasion- 
ally arises in the course of exophthalmic goiter and epilepsy. 

Some drugs produce glycosuria, such as chloroform and 
bromid of potassium. Occasionally glycosuria results after 
the acute infectious diseases, such as enteric fever, influenza, 
malaria, and syphilis. 

It has been supposed that the disease is of microbic origin, 
but the question is by no means settled. It is probable that 
the acute infectious diseases decrease the resistance of the pan- 
creas to the invasions of the micro-organisms which occur so 
abundantly in the intestines. Pregnancy and parturition occa- 
sionally give rise to the condition, and the disease shows itself 
in the course of some diseases of the liver and pancreas, 
in malignant diseases of the abdomen, after exposure, and 
after the ingestion of cold foods. 

Pathology. — The body of one dying of diabetes generally 
shows wasting, and even extreme emaciation. Occasionally, 

59o 



DIABETES MELLITUS. 591 

however, the subcutaneous fat may be quite well preserved. 
The skin is thin, the hair is scanty, the teeth are defective, and 
there are often scars left by boils or carbuncles. The brain 
presents no constant lesion. Often there is congestion and 
edema, with some thickening of the membrane ; less often 
anemia of these structures is present. Occasionally tumors 
of the fourth ventricle and of the medulla are found, or 
softening, sclerosis,, and congestion of those parts may be 
present. Glycogen has been found in large quantities in the 
medulla and in the sheaths of the vessels of the cortex. The 
cord presents no lesions that are characteristic. 

The heart is often pale and flabby. Pericarditis and endo- 
carditis occur, and fatty degeneration of the muscular fibers 
is common, and occasionally they are found loaded with fat. 

Chemically, the blood contains larger quantities of sugar 
than in health. 

The lungs show changes, congestion, edema, and sometimes 
tuberculosis. Pleurisy and empyema occasionally occur. The 
liver is enlarged and soft ; it is rarely smaller. Often a cer- 
tain amount of interstitial hepatitis is present. This form of 
cirrhosis is sometimes associated with bronzing of the skin. 
When there is abscess of the liver, there is usually a causal 
relation between the two conditions. The spleen is small, pale, 
and flabby. It may, however, be enlarged and congested. 

Great attention of late has been directed to the pancreas, 
and atrophy of this organ has been found in many instances. 
Various degrees of interstitial inflammation, with the formation 
of large areas of new tissue, are commonly present. Occa- 
sionally cancer of the pancreas has been found associated with 
diabetes. Cystic disease and pancreatic abscess have also been 
noticed. The stomach and intestines show no changes that 
are characteristic. 

Some change usually takes place in the kidney, but it is 
probably secondary to other changes. Commonly there is 
enlargement and fatty degeneration. Occasionally the cortex 
is thin and the organ contracted. Hyaline transformation of 
the epithelium of the tubes is frequently present. The kidney 
may present all the evidences of chronic diffuse nephritis. 

Symptoms. — Two varieties have been described — the acute 
and the chronic. 

Acute diabetes occurs in persons under forty, and most 
often in children or young adults. The symptoms consist in 
rapidly oncoming weakness, great thirst, and the passage of 



592 CONSTITUTIONAL DISEASES. 

excessively large quantities of urine. The frequency of mic- 
turition interferes with sleep. This gives rise to great consti- 
tutional depression. The appetite may be increased, even 
voracious, in spite of which the weight rapidly diminishes. 
The skin is dry, the lips are parched, the tongue is red and 
sticky and covered with dark fur, and the secretions from the 
mouth and bowels are diminished. 

There is frequently a complaint of a nauseous, sweet taste 
in the mouth, and the breath may even have a fruity odor 
(acetone odor). Muscular strength is impaired, the patient is 
depressed mentally, and sexual desire is lost. The urine may 
vary in quantity from five to twenty pints or more, and it con- 
tains a large percentage of sugar. 

Chronic diabetes is the more frequent form. It occurs 
in elderly persons of both sexes, and often in those who are 
decidedly obese. These patients complain of progressive 
weakness, frequency of micturition, especially at night, and 
loss of flesh, as well as decrease in sexual desire. Mental 
depression and disturbance of the digestive organs, with the 
passage of large quantities of urine, result. 

The external appearance is not characteristic, although there 
may be a peculiar flush upon the cheeks, which may even 
extend over the entire face. The odor of the breath is often 
significant. 

The nutrition of the skin suffers, so that the epidermis is dry 
and rough, the nails are brittle, and the hair is thin and dry. 
The temperature of the body is often subnormal, but at the 
onset of some acute cases the temperature may reach 103 ° F. 
or over. There is often great irritability of temper. Neuralgic 
affections are common, and the knee-jerks may be either dimin- 
ished or lost ; often, however, they are normal. In women 
menstruation is often deficient or absent altogether. The 
appetite is good, commonly excessive. The bowels are usually 
constipated. The stools may have a fetid odor. 

The cardiac impulse is in its normal position, but is often 
diffused and weak. The pulse may early show high pressure, 
but in later stages it becomes small and feeble, and is not 
increased in frequency except when complications occur. A 
rapid pulse is significant of oncoming coma. The blood con- 
tains an excess of sugar and its alkalinity is reduced. The 
microscopic appearances, however, are usually normal. In 
advanced cases some anemia may occur. Sugar may be 
present in the sweat, tears, and saliva, and the body-weight 



DIABETES MELLITUS. 593 

as a rule, undergoes rapid diminution. The constant presence 
of sugar in the urine is the important symptom of the disease. 

Temporary glycosuria may occur in many surgical condi- 
tions, after injuries, in some nervous diseases, and in gout and 
other general maladies, but the persistent presence of sugar is 
significant of diabetes mellitus. 

Urine. — The urine is greatly increased in quantity, but may 
vary within wide limits. If there is great diarrhea, the urine 
may be normal, or even lessened in quantity. The specific 
gravity is high, varying from 1025 to 1 050. As low a spe- 
cific gravity as 10 13 has been observed. The color is a pale 
greenish-yellow, but it may vary to deep amber. It is usually 
clear, but may be turbid from the presence of solids. It does 
not decompose so rapidly as normal urine, and affords a favor- 
able medium for the growth of the yeast fungus. It is always 
strongly acid in reaction, and uric acid crystals are deposited 
in considerable amount. The urea is often diminished ; the 
amount of sugar varies greatly. Acetone and diacetic acid 
are sometimes present in the urine. 

Digestive Symptoms. — Hunger is one of the important 
symptoms. As a rule, impaired digestion does not occur. 
Occasionally, there are fatty stools, suggestive of pancreatic 
disease. Diabetic patients are more than ordinarily suscep- 
tible to the poison of enteric fever, but the attacks are usually 
of mild type. In the course of the fever the sugar may disap- 
pear from the urine. 

Cutaneous Affections. — Boils, carbuncles, and skin erup- 
tions are extremely frequent. Erythema is common. The 
palms of the hands and soles of the feet may burn intensely, 
and perspiration may be profuse. Occasionally general sweat- 
ing occurs. Eczema of the genitals, especially in women, is 
a distressing symptom. Purpura has also been observed. 

There are sometimes small areas of necrosis of the skin at 
the ankles and on the dorsa of the feet, the disease beginning 
in a sweat-gland. Cellulitis and gangrene occur in the diabetes 
of advanced age, and are more frequent in men than in women. 

The temperature in the axilla may be subnormal, especially 
in the morning, whereas in the evening it may be subfebrile. 
Neuralgias of various kinds are common complications, and 
sciatica, and especially bilateral sciatica, is suggestive of dia- 
betes. Occasionally symptoms resembling locomotor ataxia 
occur. They are due to the neuritis affecting the sciatic 
nerves and their branches. 
38 



594 CONSTITUTIONAL DISEASES. 

Affections of the Special Senses. — Diabetes causes im- 
paired vision by weakening the muscles of accommodation ; 
also by diminishing the perception of light in the retina. 
Cataract, most often of the soft variety, occurs ; it may develop 
very rapidly in young subjects. Inflammation of the retina 
and atrophy of the optic nerve may also take place. 

The senses of smell and taste may be impaired. Deafness 
from otitis media has occurred. 

Diabetic Coma. — The disease may terminate in coma, which 
occurs at all ages and in both sexes, but is more liable to take 
place in the young. The exciting causes are supposed to be 
fatigue, excitement, exposure to cold, and intercurrent acute 
affections. 

The pathology of the condition is obscure. The onset of 
the coma may be preceded by languor and weakness. The 
urine may diminish in amount and the specific gravity become 
lower. An increased rate of respiration is an important symp- 
tom. In the majority of cases, however, the condition is 
ushered in without warning by delirium, often with maniacal 
excitement, with hurried and deeper respiration, drowsiness 
soon appearing, which lapses into coma. 

The patient breathes from thirty to forty times a minute, 
with deep, sighing respirations ; the pulse is rapid (from 1 30 
to 150 a minute) and feeble. The face is pale, the extremities 
•are cold, and the temperature is subnormal. The secretion 
of urine is diminished and sometimes suppressed. The bowels 
are occasionally constipated. Death may be preceded by a 
rise in temperature, to from 103 F. to 104 F., with convul- 
sions and cyanosis. A peculiar odor of the breath is often 
present, but is not constant. The urine contains acetone, and 
is frequently albuminous. 

Duration. — In children and young adults the disease is 
acute, as a rule, and rapidly fatal, lasting from a few weeks to 
a few months or two years. In elderly persons, especially 
those who are fat, the disease may continue many years. 

Diagnosis. — Diabetes may rarely exist without the presence 
of many of the symptoms just described. The occurrence 
of polyuria, with itching, especially of the genitalia, is always 
suspicious. The absolute- diagnosis consists in the constant 
presence of sugar in the urine. 

Prognosis. — The disease is always a grave condition. Cases 
which occur after injury and those which occur acutely are 
usually rapid in their course. The occurrence of gout and 



DIABETES INSIPIDUS. 595 

obesity, with early treatment, are favorable conditions. A 
marked family tendency to diabetes or to nervous diseases is 
unfavorable. Death may ensue from any complication, or 
from pulmonary phthisis, which is a common concomitant. 
An acute infectious process affecting a diabetic subject is very 
likely to terminate fatally. Death frequently takes place from 
gangrene, which may result from trivial causes, such as a 
slight scratch, or cutting- of a corn, etc. 

Treatment.: — The diet is important ; the carbohydrates 
should be restricted as much as possible. Sugar should not 
be allowed in any form. The food should consist largely of 
meats, fish, poultry, eggs, green vegetables and those that are 
not starchy (such as string-beans, lettuce, water-cress, spinach, 
young onions, tomatoes, olives, and celery), milk, cream, butter, 
cheese, and water in large quantities, especially alkaline min- 
eral waters. Climatic treatment, such as the cures at Vichy 
and at Carlsbad, is of great importance. Exercise and sys- 
tematic massage are necessary. 

Bathing should be allowed if not prolonged and not involv- 
ing violent exertion. Warm baths and steam baths are espe- 
cially grateful to the dry, irritated skin. Of drugs, opium 
and its alkaloids are the most important. Tonics should be 
given from time to time, and of these, arsenic in some form 
is perhaps the best. For the diabetic coma, brisk purging is 
necessary ; alkalies, such as potassium citrate in large doses, 
and copious drafts of water are useful. 

Hypodermoclysis of a normal salt solution, inhalation of 
oxygen, strychnin hypodermically, are also of use in diabetic 
coma. 

DIABETES INSIPIDUS. 

Synonyms. — Polyuria ; diuresis ; polydipsia. 

Etiology. — Age is a predisposing cause, the disease occur- 
ring most frequently before the thirtieth year. Heredity is 
important, and diabetes insipidus is more prevalent in the 
male sex. The disease sometimes follows violent emotions, 
such as fright, and also follows the ingestion of large quanti- 
ties of fluids. It may develop during convalescence from 
acute diseases, such as enteric fever. It occurs occasionally 
in association with abdominal tumors, tuberculosis, peritonitis, 
and syphilis. Disorders of the nervous system are supposed 
to play an important part in the causation, such as injury 



596 CONSTITUTIONAL DISEASES. 

to the cerebrospinal axis. It occurs in association with intra- 
cranial tumors and in epileptics. 

Pathology. — The pathology is obscure. No structural 
lesion has been found to account for the disease. Diabetes 
insipidus is believed to be due to a relaxation of the vessels 
of the kidney. 

Symptoms. — The two symptoms which call attention to 
the disease are the passage of large quantities of urine and 
excessive thirst. It may begin either rapidly or insidiously. 
It is often found following injuries, excessive indulgence in 
water or in alcoholic beverages, excitement, and fright. 

When diabetes insipidus is associated with chronic affections 
of the brain and spinal cord, the onset is often insidious. The 
quantity of urine may vary in individual cases, and as much 
as eight or ten quarts may be passed in twenty-four hours. 
The urine is of light yellow color, and may present a greenish 
appearance. It is feebly acid or neutral in reaction. The 
specific gravity is low, rarely reaching as high as 10 10. The 
urine, as a rule, does not contain abnormal ingredients, 
although albumin is occasionally noted. Thirst is excessive. 
The secretion of saliva is diminished and the mouth is dry. 
From the diminished secretion of sweat the skin becomes dry 
and harsh. The digestion is normal, and gastro-intestinal 
symptoms rarely occur, although constipation from dryness 
of the feces may be an important symptom. The temperature 
is often subnormal. These patients are not subject to cuta- 
neous and pulmonary or other complications, which are so fre- 
quent in those suffering from diabetes mellitus. The disease 
is of long duration ; however, some cases run a rapid course. 

Diagnosis. — The diagnosis depends upon the large quan- 
tity of urine of low specific gravity, the absence of sugar, and 
the age of the patient. 

Differential Diagnosis. — 

Diabetes Insipidus. Chronic Interstitial Nephritis. 

Age Before the thirtieth year. Middle and advanced age. 

Urine Very large quantities ; Large quantities ; low specific grav- 

low specific gravity ; ity ; traces of albumin and casts 

rarely albumin and may be present. 

casts. 



Vascular changes Not present. 


Hypertrophy of heart ; accentuated 
second aortic sound ; arterioscle- 


Eye symptoms . Absent. 
Course .... Rarely fatal. 


rosis. 
Common ; albuminuric retinitis. 
Progressive, always terminating 

fatally. 



CHRONIC RHEUMATISM. 597 

Prognosis. — The prognosis as to life is favorable, but the 
condition is rarely curable. Cases associated with syphilis may 
recover upon antisyphilitic treatment. 

Treatment. — There may be diminution in the quantity of 
urine and alleviation of thirst under treatment, although the 
condition itself is incurable. Opium is the most useful drug, 
but it may interfere with digestion, and there is great danger 
of the opium habit being acquired. Ergot is occasionally of 
some use. 

CHRONIC RHEUMATISM. 

Definition. — Chronic rheumatism is characterized by grad- 
ual and permanent changes in the joint structure, producing 
more or less deformity. The condition often begins insidiously. 

Etiology. — The disease is most common in females, and 
rarely develops before the fortieth year of life. Bad hygiene, 
exposure to cold and damp, and malnutrition are etiologic 
factors. Heredity is supposed to have some influence. Occa- 
sionally the disease has been seen to follow acute attacks. 

Pathology. — Moderate thickening of the joints, with con- 
traction of newly formed fibrous tissue, often ensues. The 
phalangeal joints of the fingers are commonly affected, as are 
also the knee-joints. The disease shows slight tendency to 
symmetry, but this is less striking than in similar conditions, 
such as arthritic deformities. The joint may show some 
degree of synovial injection and effusion. 

Symptoms. — The symptoms are confined to the joints, and 
there is no tendency to involve the serous membranes of the 
heart. The fingers are distorted by contraction of the tendons 
or ligaments, and deflections, especially of the ulna, are likely 
to occur. The knees become thickened and stiff, so that the 
legs can be but partly extended. A crackling may some- 
times be heard and felt upon attempting forcibly to extend 
the part. Redness and edema about the joints are rare. 
The joint is often much deformed. Atrophy of the muscles 
may take place about the affected articulation. Constitu- 
tional symptoms are mostly absent. Occasionally slight 
fever ensues from exacerbation of the joint symptoms. The 
urine is normal ; the general health is good ; there is occa- 
sional anemia and debility. 

Prognosis. — The prognosis as to life is good. The condi- 
tion, however, is incurable. 

Treatment. — Local treatment is important, hydrotherapy 



59$ CONSTITUTIONAL DISEASES. 

yielding good results. The application of hot air in suitable 
apparatus often gives great relief from pain and stiffness. 
Massage is also useful. Care should be taken to avoid ex- 
posure to cold or wet. Internal remedies are of very little 
benefit. Occasionally syrup of the iodid of iron and the com- 
pound syrup of the hypophosphites are valuable. Cod-liver 
oil and arsenic as tonics are useful. 



GONORRHEAL ARTHRITIS. 

Definition. — An infectious disease, characterized by specific 
urethritis, more rarely conjunctivitis, due to the gonococcus, 
and by localized inflammation of one or more of the larger 
joints, especially of the extremities. 

Synonyms. — Gonorrheal rheumatism ; gonorrheal syn- 
ovitis. 

Etiology. — The disease has no relation to articular rheu- 
matism, and has been erroneously called gonorrheal rheuma- 
tism. It is due to the migration of the gonococcus, or its 
toxins, into the joint. The etiology, therefore, depends upon 
the occurrence of a gonococcous infection. 

Pathology. — The affected joint shows the condition com- 
mon in synovitis. The capsule, synovial membranes, and 
ligaments are inflamed and thickened. Frequently there is an 
effusion into the joint, which is rarely purulent. It most 
often occurs in the knee-joints and ankles. Occasionally the 
inflammation becomes peri-articular, and extends along the 
tendon sheaths, invading the periosteum and causing consid- 
erable edema. In the chronic form there is often much effu- 
sion into the joint. This occurs most commonly in the knee, 
whereas slight edema appears in the wrist and ankle. As the 
inflammation subsides, the joint recovers less completely than 
in rheumatic fever, as fibrous adhesions and thickening com- 
monly remain, producing impairment of motion, and occasion- 
ally ankylosis. 

Symptoms. — In the acute form the symptoms are mild, 
and several joints may be involved simultaneously. In the 
severe, and especially in the chronic, form the disease is often 
confined to one joint. ■ 

The symptoms are usually preceded by a cessation in the 
flow of pus from the urethra, and the affected joint becomes 
more and more painful and swollen. The smaller joints are 
not often involved. The inflammation remains, and does not 



MUSCULAR RHEUMATISM. 599 

show ihe fleeting character so common in rheumatic fever. 
The pain is not so intense and redness is not so prominent as 
in acute articular rheumatism. The pain is constant and in- 
tense, often worse at night, preventing all motion of the 
affected joint. The pain often subsides before the swelling 
disappears. Fever is moderate, from ioi° F. to 103 F. 
Sweating is not common. Anemia of the chlorotic type is 
often marked. Anorexia and constipation may occur. 

Complications. — Complications are rare. The serous 
membranes of the heart may become involved, the other viscera 
escaping. Malignant endocarditis has been seen to follow 
this affection, gonococci having been found in the endocardium. 

Diagnosis. — The diagnosis depends upon the occurrence 
of arthritis following a specific urethritis or, more rarely, 
specific conjunctivitis in children. The fact that one joint is 
affected, and the absence of sweating and of cardiac affections, 
differentiate the condition from acute rheumatic fever. 

Prognosis. — Recovery takes place very slowly, and is pro- 
longed and tedious. There is occasionally permanent stiffness 
and ankylosis. Relapses are liable to occur with a re-infection. 

Treatment. — Increasing doses of the syrup of iodid of 
iron have proved efficacious in the treatment of this disease. 
Tonics are necessary on account of the progressive anemia. 
Cod-liver oil and iron are valuable for this purpose. Local 
applications are of use, and the joint should not be kept im- 
mobile too long on account of the tendency toward ankylosis. 



MUSCULAR RHEUMATISM* 

Definition. — A diseased condition of the voluntary muscular 
structures, often involving the surrounding fascia and the peri- 
osteum to which the muscles are attached, accompanied by 
pain and slight swelling. 

Synonym. — Myalgia. 

Etiology. — The disease is more common in men than in 
women, owing to the greater exposure and to cold. It often 
occurs after a wetting from rain, or from sitting in a draft 
of air, as at an open window. Gouty and lithemic indi- 
viduals are very subject to attacks of muscular rheumatism. 
One attack renders the affected person more liable to subse- 
quent suffering upon exposure. As a rule, the disease is 
acute ; it may, however, be subacute or even chronic. 



600 CONSTITUTIONAL DISEASES. 

Pathology. — This is by no means understood, some ob- 
servers claiming that the affection is not due to the muscles, 
but is due to disease of the sensory nerves ; that, in fact, the 
affection is a neuralgia. 

Symptoms. — The prominent symptom of the disease is 
local pain, without constitutional disturbance, and even in the 
most aggravated cases fever is entirely absent. The pain varies 
in severity from a slight dull ache to that of a sharp, stabbing, 
or lancinating character, and is increased by certain move- 
ments. Pressure upon the affected area usually gives prompt 
relief. The affection lasts from a few hours to some days, the 
subacute and chronic cases being more prolonged. 

Lumbago is a form of myalgia involving the muscles of 
the back. 

Torticollis, or stiff neck, affects the muscles of the neck, 
and is mostly unilateral. 

Pleurodynia is a form of myalgia affecting the muscles of 
the chest. 

Treatment. — Rest of the affected parts, hot applications 
(mustard plasters), hypodermics of morphin, and large doses 
of the salicylates will, as a rule, prove effective. In lumbago 
acupuncture is highly recommended. Turkish baths, the hot- 
air apparatus, and electricity are useful in protracted cases. 

RICKETS. 

Definition. — Rickets is a constitutional disease characterized 
anatomically by bone resorption and the formation of new 
osteoid tissue ; clinically, by gastro-intestinal disturbance and 
nervous symptoms. 

Synonyms. — Rachitis ; morbus anglicus. 

Etiology. — The disease is caused by improper and per- 
verted nutrition, affecting all the structures of the organism. 
Faulty diet has been given a prominent place in the produc- 
tion of the disease, in causing gastro-intestinal disturbance, 
accompanied by vomiting and diarrhea. General bad hygiene, 
improper clothing, lack of fresh air and ventilation, and in- 
herited syphilis are predisposing factors. It is most probable 
that many of these causes acting together are capable of pro- 
ducing the affection. The disease is most commonly met with 
in the temperate zone, decreasing in frequency as northern or 
southern limits are reached. The cold winter months show 
the larger number of cases. It is equally prevalent in both 



RICKETS. 60 1 

sexes. It has not been definitely determined whether the dis- 
ease is hereditary. It is quite remarkable that the evidences of 
congenital syphilis are almost entirely absent in rickety chil- 
dren. The principal causative factor is a faulty diet. Fari- 
naceous food without the addition of milk is liable to produce 
rickets. 

Pathology. — Various deformities of bone result in this dis- 
ease, these consisting principally of bowing or bending of the 
long bones, such as the femur. The tibia may bend forward ; 
the bones of the head may become altered so that the head 
becomes box-shaped. Early in the disease the parietal bones 
become thinned as a result of the bone resorption. Upon 
palpation of the frontal or parietal bone a peculiar crepitation, 
resembling that of a parchment-like membrane, is detected, 
this being called craniotabes ; later, nodes develop upon the 
frontal and parietal bones. Deformities also arise in the shape 
of the chest, so that the characteristic pigeon-breast develops. 
The sternum becomes thickened ; enlargements develop at the 
ends of the ribs near the costal cartilages, giving rise to what 
is known as the racldiic rosary. In the spine, curvatures are 
common (scoliosis and kyphosis). The pelvic bones become 
enlarged and thickened, and the characteristic funnel-shaped 
pelvis develops. Nodes are also noted at the ends of the long 
bones. Enlargements of the liver and spleen, chiefly due to an 
increase in fibrous connective tissue ; pronounced anemia, and 
catarrh of the gastrointestinal tract are also encountered. 
Leukocytosis with particular increase in the lymphocytes is 
common. 

Symptoms. — The onset of the disease is insidious. The 
period of its first dentition is delayed, which often masks the 
onset of the disease. Gastro-intestinal disturbances give rise 
to disordered nutrition. The child is peevish and irritable, the 
temperature frequently being subfebrile. Profuse sweating, 
restlessness, and sleeplessness, with the fever ranging from ioo° 
F. to 102 F., and a general soreness over all the body, are 
likely to arise early, as has been described in the pathology. 
The shape of the head is characteristic ; it appears rectangular, 
the face seeming small in proportion to the skull. 

Occasionally, a systolic murmur may be heard by listening 
over the anterior fontanel. Commonly the spleen is enlarged. 
The urine contains an excess of the lime-salts. Some degree 
of anemia is always present ; it is commonly of the chlorotic 
type. The nervous symptoms are usually prominent. There 



602 CONSTITUTIONAL DISEASES. 

is restlessness and lack of sleep, and laryngismus stridulus 
sometimes occurs. Tetany is not uncommon. 

Prognosis. — The intercurrent affections which develop in 
this disease are more to be dreaded than the affection itself, 
which is rarely fatal. The skeletal deformities do not dis- 
appear. 

Treatment. — The child should have the best of food, and 
if the mother can not nurse it, a wet-nurse should be procured. 
Abundance of fresh air and sunshine are essential. Daily 
bathing in warm water is necessary. The child should not be 
encouraged to walk. The drugs that have been recommended 
are phosphorus, cod-liver oil, and the syrup of the iodid of 
iron. 

ARTHRITIS DEFORMANS. 

Definition. — A chronic joint affection, characterized by 
great progressive deformity, with functional and anatomic 
changes in the osseous, cartilaginous, and synovial structures. 

Synonyms. — Rheumatoid arthritis ; rheumatic gout. 

Etiology. — The disease bears no relation to either rheu- 
matism or gout. The exciting cause is still unknown, and by 
many it is supposed to be of nervous origin. The view that 
the disease is of microbic origin has lately been advanced by 
Max Schiller, who describes a peculiar form of bacillus ob- 
tained from the fluid of the diseased joints. The same micro- 
organism was also found in the blood of the persons affected. 

The disease occurs more often in the female sex, in the pro- 
portion of five to one. It may appear at any age, but the 
greater number of cases develop in young adults between the 
ages of twenty and thirty. In a few instances the disease has 
appeared to be hereditary. Bad hygiene, mental strain, worry, 
grief, and care have been cited as etiologic factors. The dis- 
ease shows an especial tendency to develop among the poorer 
classes ; however, the well-to-do do not escape. 

It is sometimes associated with chronic pulmonary tuber- 
culosis. It has followed attacks of influenza, and sometimes 
arises in sterile women. 

Pathology. — The disease involves all the structures of the 
joint, and the nutrition of the affected part suffers greatly. 
The lesions usually begin in the cartilages of the articulations, 
where the circulation is lessened and the friction greatest. 

The cartilages of the joints become softened, thinned, and 
gradually so nearly absorbed that the ends of the bone are in 



ARTHRITIS DEFORMANS. 603 

apposition ; proliferative changes ensue at the extremity of the 
bones, which become thickened ; osteophytes develop (which 
are called Haygarth's nodosities), the ligaments are thick- 
ened, and finally partial ankylosis may result. The muscles 
around the joint become atrophied, and the nerves may show 
some degree of inflammatory change. In long-standing cases 
the ends of the bone may undergo atrophy and softening. 
The small joints of the hands and feet are most frequently 
involved ; however, some of the larger joints are sometimes 
affected. Deposits of urate of soda are never found around 
the joints. 

Symptoms. — The disease shows great variability in its 
mode of onset ; it is common for the affected person to go to 
bed apparently healthy, and to awaken in the night with a 
sharp pain, especially in the joints. There is a sense of ting- 
ling and burning in the affected part. Soon a swelling takes 
place in the affected joint, which comes on exceedingly slowly. 
The metacarpophalangeal joints are those most commonly 
affected. In some cases hard nodules develop at the sides of 
the distal phalanges ; these are known as Heberden's nodes. 
The disease may now be quiescent for months and years ; 
sooner or later, however, other joints are attacked, the swell- 
ing and pain in the mean time never entirely subsiding in 
the joints which were primarily affected ; the condition may 
continue until nearly every joint in the entire body has become 
affected. At first there may be synovial effusion under the 
implicated articulation ; this is followed by atrophy in the 
muscles of the involved parts, and occasionally this atrophy 
is in advance of the joint implication. The nutrition of the 
parts is affected, especially the nails of the hands and feet. 
Bursal swellings sometimes occur in the neighborhood of the 
affected joints, especially upon the dorsal aspects of the wrists. 
If the disease exists in the joints of the hand or foot, the char- 
acteristic fin-like deformity develops. Almost from the be- 
ginning of the disease there is increased rapidity of the heart's 
action ; the pulse gradually rises from 90 to 1 20 or more per 
minute. This vascular disturbance is not associated with 
cardiac murmurs ; even functional murmurs are absent, as a 
rule. Generally, during the course of the attack fever does 
not occur, but with each fresh outbreak a temporary sub- 
febrile range of temperature may be encountered. Pigmenta- 
tion and glossiness of the skin of the affected area are often 
observed. This disease is found among children, girls being 



604 CONSTITUTIONAL DISEASES. 

more frequently affected than boys, the onset being accom- 
panied by fever. The spleen and lymphatic glands may be 
enlarged, the joints become stiffened, and the functions limited, 
accompanied by muscular wasting. 

Prognosis. — The prognosis as to cure is unfavorable ; how- 
ever, life may be prolonged for many years. Under proper 
treatment it is sometimes possible to arrest the progress, but 
the affected joints can never be restored to their normal func- 
tions. 

The treatment consists in appropriate diet and in careful 
hygiene. As a rule, meat should be liberally allowed, with a 
suitable vegetable diet. Exposure to wet and cold must be care- 
fully avoided, and, if possible, the patient should live in a warm, 
dry climate. Massage, warm baths, and electricity are of 
decided use. The hot-air treatment has also proved of de- 
cided benefit in some cases. The drugs which are of most value 
in the treatment of this condition are the iodids, particularly 
the syrup of the iodid of iron, and arsenic. Cod-liver oil is of 
use as a general tonic. Arsenic should be given in increased 
doses to the point of tolerance as a tonic. 



GOUT. 

Definition. — Gout is a constitutional disease, characterized 
by polyarthritis affecting particularly the small joints and by a 
deposition of urate of soda in and about the articulations. 

Synonym. — Podagra. 

Etiology. — The disease occurs most commonly between 
the ages of thirty-five and fifty, except in the cases marked by 
strong hereditary tendency, in which the affection may show 
itself much sooner. It is more common in the male than in 
the female. Corpulent persons are more predisposed to be- 
come gouty, especially those of sedentary habits. Errors in 
diet are extremely likely to bring on the affection. This 
applies particularly to the indulgence in red meats and alco- 
holic beverages. Chronic lead-poisoning also predisposes to. 
attacks of gout. The disease occurs in the well-to-do much 
more frequently than in the poor ; in the latter it is due to 
overindulgence in malt liquors (poor man's gout). 

Pathology. — In gout an increase in urates is found in the 
blood, which gives rise to supersatu ration, and it is believed 
that this causes the inflammatory changes which develop in 



GOUT. 605 

the joints. The involvement first begins in the articular carti- 
lage, thence spreading to the other joint-structures. The char- 
acteristic chalk-like deposits (urates) are formed. The joint 
most commonly involved is the metatarsophalangeal joint of 
the big toe on the right side. The ankle, knee, small articula- 
tions of the wrist, and the hand are also sometimes involved. 
Chronic interstitial changes are common in many organs, espe- 
cially in the blood-vessels and the kidneys. 

Symptoms of Acute Gout. — The first attack begins sud- 
denly, and usually at night, with intense pain in the great toe, 
particularly involving the metatarsophalangeal articulation. 
In the morning it is noticed that the joint is red, swollen, 
tense, and exquisitely painful. With this there is a slight 
rise in temperature, the urine being scanty and high-colored 
and containing sediment (urates). There is great thirst and 
anorexia. Toward morning the pain subsides somewhat, but 
in the evening returns with increased severity. The fever 
continues to rise. Upon the following two or three days the 
swelling in the joint increases. The pain, however, diminishes, 
and the fever subsides. The attacks commonly last from a 
week to ten days. The tenderness and swelling, as a rule, pass 
away, and the health is restored. Occasionally, it happens that 
other joints are affected besides those of the great toe, par- 
ticularly the tarsal and metatarsal joints, and the opposite foot 
may become involved. In cases of this sort the paroxysm is 
more prolonged, lasting from two to three weeks ; however, 
recovery from the first attack is usually quite complete. 
There may now be an interval of about three years or longer 
before the attack recurs, and after this as the attacks return 
from year to year they are liable to show marked periodicity, 
occurring in the spring and fall. As the disease progresses, 
the larger joints may also become involved, and with each 
succeeding attack recovery is less complete, so that the joints 
become permanently enlarged, stiff, and deformed, and the 
characteristic chalk-stones make their appearance in the hands 
and the toes, at the knees and the elbows. Large quantities 
of urates are often found in the urine just after the onset of or 
following the attack. After the first seizure the patient often 
has prodromes which warn him of the oncoming of an attack ; 
they most commonly consist of digestive disturbances, such as 
loss of appetite, pyrosis, flatulency, and irregular action of the 
bowels. There may be marked nervous disturbances, such as 
cramps, irritability of temper, neuralgia, depression of spirits, 



606 CONSTITUTIONAL DISEASES. 

and cardiac palpitation. These prodromal symptoms disap- 
pear suddenly as the seizure comes on. 

Symptoms of Irregular Gout. — As a rule, between attacks, 
especially when the disease has existed but a short time, the 
patient is free from pain, but this is not invariably so. In 
chronic cases, especially after repeated attacks, the patient is 
troubled with irregular pains in the joints, and with many gas- 
tric and nervous symptoms, just as in the acute form, except 
that they are much less severe. This condition has been termed 
chronic or irregular gout. Occasionally, it happens that the in- 
flammation in the gouty joints subsides suddenly from expo- 
sure to cold or as the result of the application of cold to the 
joints. This condition is often followed by severe symptoms 
referable to some internal organ, such as the brain, heart, or 
stomach. The condition is serious, and often has a fatal issue. 
It is known as retrocedent gout. 

Symptoms Referable to the Skin. — Eczema is common, 
especially of the face, forehead, external ear, neck, and back. 
As a rule, it is not severe, but is persistent. Psoriasis may 
occur. Pruritus, local or diffused, which is apt to be trouble- 
some at night, is common. The nails become brittle, and are 
kept in order with difficulty. 

Symptoms Referable to the Eye. — Conjunctivitis and scle- 
rotitis are the most common affections of the eye in this 
disease. Glaucoma, retinitis, and gouty iritis have been known 
to occur. 

Diagnosis. — The diagnosis of acute gout depends upon the 
sudden onset with the arthritis, with special exacerbations «at 
night, affecting the small joints, and upon the gastric and 
nervous symptoms. The disease rarely occurs before the age 
of thirty or thirty-five. 

Prognosis. — The prognosis depends upon the appearance 
of complications ; when these are absent, the prognosis is 
good. If the kidneys remain sound, the general health is not 
appreciably lowered. Albumin occurring in the urine is always 
an unfavorable sign. 

Treatment. — Diet and General Hygiene. — As nearly as 
possible a vegetable diet should be adhered to, as animal food 
gives rise to uric acid. Water should be partaken of plentifully. 
Alcoholic and malt liquors, especially the rich, sweet wines, 
such as port, sherry, and champagne, should particularly be 
prohibited. Systematic bathing, regular exercise in the open air, 
avoidance of exposure to cold and dampness, are important. 



LITHEMIA. 607 

Treatment of the Paroxysm. — A mild laxative at the onset 
is useful. If the patient has fever, he should be confined to 
bed, and the affected joints kept at rest, and a diet of milk and 
farinaceous articles, with plenty of water, should be insisted 
on. Bleeding and venesection are contraindicated. The 
joints should be wrapped in cotton-wool. If the pain become 
severe at night, opium in some form must be administered. 
For the attack itself, colchicum is the remedy ; from 10 to 20 
drops of the wine or tincture may be given two or three times 
daily. In cases in which colchicum is not well borne, iodid 
and bromid of potassium are useful. The salicylates or the 
salts of lithia may be of value. 

LITHEMIA. 

Synonyms. — American gout ; irregular gout. 

Etiology. — Excessive indulgence, especially in nitrogenous 
food, the abuse of alcohol, lack of proper exercise, and 
heredity have been given as predisposing factors. The neu- 
rotic temperament is said to favor the development of the 
affection. 

Pathology. — The pathology is similar to that of gout, ex- 
cept that the joints are not particularly involved, and it is 
probable that lithemia is due to an accumulation of urates 
in the blood, as is gout. Da Costa describes lithemia as " a 
morbid state where the income of nutriment is in excess of the 
output of waste." Sclerotic changes in the liver, the kidneys, 
and the blood-vessels are commonly encountered in advanced 
cases of lithemia. 

Symptoms. — The symptoms are frequently vague, but 
relate particularly to the nervous and digestive systems. The 
skin and the genito-urinary and circulatory systems, however, 
also commonly give rise to more or less characteristic phe- 
nomena. There is frequently vertigo ; tinnitus aurium, in- 
somnia, restlessness, sensations of heat in the soles of the feet, 
headache, which may be either occipital or general, and occa- 
sionally affecting one-half of the head (hemicrania), and hypo- 
chondriasis are noted. Gastro-intestinal symptoms are com- 
mon ; the appetite is variable. The tongue is commonly 
coated ; sometimes, however, it is red and dry. There is 
pyrosis, cardialgia, sensation of weight in the epigastrium, 
hiccup, occasionally nausea and vomiting, and flatulence, 
which exists to such an extent that it is distressing- to the 



608 CONSTITUTIONAL DISEASES. 

patient. Hemorrhoids are common ; they may be due to cir- 
rhotic involvement of the liver, which is often tender when 
pressed upon. The terms " biliousness " and "torpid liver," 
used so commonly by the older writers, probably in many in- 
stances referred to the lithemic state. There is palpitation of 
the heart, which may be due either to flatulence or to an in- 
creased arterial tension. The phenomena of the skin consist 
in pruritus, eczema, urticaria, and lichen. The urine, as a rule, 
is of high specific gravity (1025 to 1035), markedly acid, of a 
dull red color, and on cooling deposits brickdust sediment. 
Phosphate of lime crystals are also commonly present. Albu- 
minuria is not at all infrequent. Casts may often be found. 
In another variety of cases neurasthenia develops. The patient 
becomes anemic. There is great muscular and mental fatigue, 
with languor. 

Prognosis. — The prognosis is good if the patient be able to 
change his mode of life and to undergo proper treatment. In 
old cases arteriosclerosis, atrophic cirrhosis of the liver, and 
chronic renal disease necessarily render the prognosis unfav- 
orable. 

Treatment. — The most important elements in treatment are 
proper diet and hygiene. Meat should be withheld in severe 
cases, the patient being put upon a diet of cereals and fruit. 
When improvement takes place, meats may be allowed once 
a day, preferably the white meats, with fish, white bread, and 
so on. In the anemic and neurasthenic cases, however, meat 
is necessary. Large quantities of aerated waters are bene- 
ficial. Sugars, sweets, and also cheese, fats, and butter, 
should be partaken of sparingly. Alcoholic beverages must 
be forbidden. Tea and coffee may be allowed only sparingly. 
Smokers had better give up the use of tobacco. Exercise, 
outdoor life, sea-bathing, change of climate, etc., are eminently 
beneficial, and long sea voyages are especially of value. The 
various mineral springs, especially Carlsbad, are particularly to 
be recommended. The medicinal treatment should consist of 
laxative doses of calomel from time to time, alternating with 
some saline, such as the phosphate of sodium. The prepara- 
tions of lithia have been generally advised. Piperazin, in 
5 -grain doses three times daily, is effective in many cases. 



OBESITY. 609 



OBESITY. 

Definition. — This condition is due to an increase in the fats 
of the body. 

Synonyms. — Polysarcia ; lipomatosis universalis ; corpu- 
lency. 

Etiology. — The disease occurs in either sex ; it is, however, 
more common in women. It frequently devolops after the 
menopause. It may be either hereditary or acquired. In the 
acquired form it results from lack of exercise and from exces- 
sive eating, and is especially common in the uric acid diathe- 
sis. It results from the use of alcoholic beverages, particu- 
larly the malt liquors. It occurs in indolent, phlegmatic 
individuals, while those of the nervous temperament are not 
inclined to stoutness. Certain diseases, such as diabetes mel- 
litus and gout, favor the development of fat.' It is also com- 
mon in chlorotic girls and in some of the severe forms of 
anemia. Corpulency may follow some diseases, such as pneu- 
monia, enteric fever, and neurasthenia, and it also develops 
after ovariotomies and castration. Deficient oxidation may 
also be included among the causes. Certain occupations 
which tend to lessen the normal activities predispose to obes- 
ity. The ingestion of large amounts of fluids is liable to 
cause corpulency. 

Symptoms. — The normal activities of the individual are 
much impaired from the accumulation of fat around some of the 
organs ; their functions become lessened, the circulation is 
likely to be poor, and degenerative changes may follow in the 
heart muscle. In some individuals plethora instead of anemia 
is found. The appetite is perverted, and, as a rule, poor ; in- 
digestion and constipation are frequently present. In some 
instances there is some degree of mental impairment, the 
individuals complaining of being tired and sleepy. The 
temperature is usually subnormal. The condition may re- 
main stationary for years. 

Prognosis. — Under appropriate treatment the body-weight 
is sometimes materially reduced, with decided benefit to the 
patient. 

Treatment. — The treatment is in the main dietetic. Food 

should be partaken of sparingly, and the starches, sugars, and 

fats must be reduced to a minimum. Systematic exercise 

and hydrotherapy are useful. Alcoholic beverages, especially 

39 



6lO CONSTITUTIONAL DISEASES. 

the heavy wines and malt liquors, are to be avoided. Some 
of the special cures, such as advised at Kissingen and Vichy, 
are beneficial. 

The administration of thyroid extract is attended with some 
danger, and it should always be cautiously employed. Good 
results have, however, followed its use. 



OSTEOMALACIA. 

Definition. — An affection characterized by softening and 
bending of the bones owing to the solution of lime-salts. 

Synonyms. — Mollities ossium ; malacosteon. 

Etiology. — The cause of the disease is not known. It 
occurs most often in females, and most frequently between the 
ages of twenty-five and forty-five. It is very commonly asso- 
ciated with pregnancy. Repeated pregnancies seem to aggra- 
vate the affection. 

Pathology. — Softening of the pelvic bones occurs early, 
and produces marked deformities of these bones, but the dis- 
ease may begin in the bodies of the vertebrae. The acetab- 
ulum is forced inward and the iliac bones are flared outward 
(winged). The lumbar vertebrae are pushed forward, and 
downward, and the sacrum and pubes are also pushed for- 
ward. The vertebrae and the femur may undergo extensive 
softening. Fractures are common in this disease. Absorp- 
tion of the lime-salts begins at the edges of the trabeculae and 
Haversian canals. 

Symptoms. — General feebleness and debility, accompanied 
by pains in the region of the pelvis and in the lower extrem- 
ities, with a peculiar unsteadiness of the gait, are early symp- 
toms. Kyphosis, lordosis, and scoliosis are common. Parturi- 
tion becomes difficult. The urine contains an increased amount 
of lime-salts. The disease is chronic, lasting for many years. 

Treatment. — The treatment consists in good hygiene and 
the use of tonics. 

PULMONARY HYPERTROPHIC OSTEOARTHROP- 
ATHY. 

Definition. — This affection is characterized by deformity 
and enlargement of the bones, affecting principally those of 
the hands, wrists, ankles, and feet in persons affected by 
chronic pulmonary disease. 



OSTEITIS DEFORMANS. 6 1 I 

Etiology. — The disease is rare, having first been described 
by Marie. It has been noted as occurring in connection with 
empyema, pulmonary tuberculosis, new growths of the lung, 
and some forms of chronic bronchitis. 

Symptoms. — The principal enlargement occurs in the fin- 
gers, which increase both in length and thickness (club de- 
formity), the nails becoming considerably curved and fibrous, 
often resembling the talons of a bird. The wrists are swollen, 
and the extremities of the radius and of the ulna are enlarged. 
The changes in the foot are similar to those described in the 
hand. The deformity of the bones is not symmetric. There 
is often swelling of the articular ends of the long bones, and 
occasionally effusions take place into the joints. Spinal curva- 
ture, especially in the dorsolumbar region, is frequent. Much 
of the pathology is still unknown. 

Treatment. — No methods are known which will remedy 
the affection. 

OSTEITIS DEFORMANS. 

Definition. — A disease characterized by marked deformity 
of different bones of the body and by constitutional disturb- 
ances. 

Etiology. — The etiology of this disease is still unknown. 
* The disease was first described by Sir James Paget, in 1877. It 
chiefly affects the aged, and is more common in males than 
in females. 

Symptoms. — The deformities may involve many bones, or 
may be restricted to one, such as the tibia or the femur. This 
is particularly true early in the disease ; later, the vertebrae, the 
skull, and other bones of the body become involved. Bowing 
of the long bones and curvature of the spine develop. In 
some parts of the bone marked absorption is going on, and is 
slight in other parts. New bone is also deposited in certain 
areas, therefore a marked deformity results. The disease 
may persist for a number of years, but it rarely causes death. 
After the disease has persisted for a while, carcinoma and 
sarcoma are apt to follow in some parts of the body. 

Prognosis. — The prognosis is unfavorable, and no remedy 
influences the course of the disease. 



part vn. 

DISEASES OF THE BLOOD AND OF 
THE DUCTLESS GLANDS. 



ANEMIA. 

By the term anemia is meant a deficiency of the blood either 
in its bulk or in certain of its constituents ; by oligemia is usually 
meant a deficiency of the blood as a whole ; by oligocythemia, 
a decrease in the number of erythrocytes ; by oligochromemia, 
a reduction in the hemoglobin. 

The classification of anemia is by no means satisfactory ; the 
one which must still be adhered to is that of primary and 
secondary anemia. By the term primary — sometimes called 
essential, idiopathic, or cryptogenetic — is meant a disturbance 
of the blood or of the blood-making organs (spleen, bone-mar- 
row, and lymphatic glands), so that the anemia seems the dis- 
tinctive feature of the disease, while other symptoms appear 
mainly dependent upon this change. Under this heading are 
properly considered chlorosis and pernicious anemia. Sec= 
ondary anemia is due to some disease acting upon the blood or 
blood-making organs, the anernia not being the prime feature, 
but a symptomatic manifestation. Perhaps a more lucid and 
scientific classification will be adopted when our knowledge 
relating to the subject becomes more definite ; for example, 
such a classification as: (i) anemia due to deficient blood 
formation ; (2) anemia due to excessive blood destruction 
(hemolysis) ; (3) anemia due partly to both these causes. 

SECONDARY ANEMIA. 

Synonym. — Symptomatic anemia. 

Etiology. — Hemorrhage. — The severity of the anemia from 
this cause necessarily varies greatly, depending upon whether 

612 



SECONDARY ANEMIA. 613 

the loss of blood be rapid or gradual, and upon the amount. 
Indeed, some of the severest forms of anemia are encountered 
from this cause. It can not be stated just how great a loss of 
blood will produce a fatal issue, as individual predisposition 
and the rapidity of hemorrhage are factors which determine 
this. Hemorrhage may occur from many causes. Rapid bleed- 
ing is often due to tuberculosis of the lungs, uterine disease, 
gastric ulcer, rupture of aneurysms, external injury, scurvy, 
purpura, hemophilia, etc. Slow hemorrhage, which often 
causes intense anemia, is due to such causes as hemorrhoids, 
carcinoma, and uterine disease. 

Improper Food or Deficiency of Food. — Anemia from this 
cause may be due to lack of food, to improper food, or to 
either functional or organic derangement of some part of the 
gastro-intestinal tract. Such conditions as stricture of the 
esophagus, due either to cicatrices or to tumors, carcinoma of 
the stomach, the various forms of gastritis and dyspepsia, 
may give rise to secondary anemia from failure to properly 
assimilate food. 

Organic diseases, particularly those diseases which cause 
a constant, long-continued drain of the albuminous materials 
of the blood, give rise to pronounced anemias. This is so of 
chronic parenchymatous nephritis, long-continued suppuration, 
diarrhea, leukorrhea, etc. Malignant tumors also produce 
pronounced anemia. 

The blood, an agent which acts upon tissues through the 
medium of other tissues, performs one of the chief func- 
tions in the complex system of animal life ; therefore a disease 
of an organ will affect other tissues through the agency of the 
blood. Diseases of the brain, spinal cord, heart, liver, kidney, 
lung, pancreas, bone-marrow, spleen, thyroid gland, and 
lymph-glands, all tend to produce anemia. 

Infectious Diseases. — In the acute infectious diseases the 
blood suffers in a marked degree, principally through exces- 
sive hemolytic action, either directly by the action of the specific 
germ or its toxin. This is particularly true of such diseases 
as acute rheumatic fever, pyemia, septicemia, diphtheria, pneu- 
monia, enteric fever, etc. The chronic infectious diseases 
produce a pronounced form of anemia. This is encountered 
in syphilis, tuberculosis, and other diseases. 

Toxic Causes. — Poisons introduced from without or devel- 
oped within the body produce anemia. Such anemia may be 
due to lead, mercury, arsenic, copper, etc. Various poisons 



6 14 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

may be absorbed through faulty digestion. In gout and rachitis 
anemia is developed. 

Animal Parasites. — These either directly or indirectly pro- 
duce anemia. The malarial parasite is an example of direct 
action upon the red blood-cell. The anchylostoma duodenale 
produces an extreme form of anemia, which is sometimes 
spoken of as u Egyptian chlorosis." The bothriocephalus latus 
also gives rise to profound anemia. Other parasites which give 
rise to anemia are the ascaris lumbricoides, the filaria sanguinis 
hominis, the oxyuris vermicularis, the cestodes, the distoma 
haematobium and the distoma pulmonalis, the amoeba coli, etc. 

Pathology. — The state of the blood depends upon the 
severity and duration of the cause acting and upon the power 
of blood regeneration, so therefore symptomatic anemia varies 
from the slightest impairment to the gravest form of anemia, 
not unlike progressive pernicious anemia. The composite pic- 
ture of the blood in secondary anemia is by no means easy of 
description. The anemia depends largely upon the power the 
individual possesses to regenerate blood. 

The fluid and albuminous principles of the blood seem to 
be quickly restored, the corpuscular elements next, and, lastly, 
the hemoglobin is replaced. The latter often requires weeks, 
or even months, before the normal standard is reached. It is 
for this reason that the greater number of secondary anemias 
show a more decided decrease in the percentage of hemoglobin 
than in the number of erythrocytes ; hence a low color-index. 
Indeed, this is sometimes so striking that the anemia is called 
by some " chlorotic anemia." The latter condition is encoun- 
tered in tuberculosis, syphilis, and cancer. In some diseases 
the plasma of the blood is withdrawn in excess of the corpus- 
cular element, so that the erythrocytes are relatively increased, 
owing to concentration ; this is encountered in cholera and in 
severe diarrheas. 

The leukocytes are usually increased in secondary anemia, 
the most important exceptions being enteric fever, tuberculosis, 
malaria, measles, and influenza. (See Leukocytosis.) The 
polymorphonuclear neutrophiles are generally increased both 
relatively and absolutely ; but there are exceptions, for the 
eosinophiles or the lymphocytes may be the only ones which 
show the increase. A few myelocytes may appear in the blood, 
particularly in grave forms of symptomatic anemia, or when 
the bone-marrow is disturbed from the pressure of tumors, etc. 

Tr. ^ythrocytes in slight anemia show little or no structural 



SECONDARY ANEMIA. 615 

change, but as the severity increases, various abnormalities 
are encountered. One of the most important changes is per- 
haps variation in size ; macrocytes and microcytes are noticed ; 
the greater number of cells seem to be under the normal size. 
Poikilocytosis also manifests itself. Nucleated cells may be 
found, particularly normoblasts. In the regeneration of blood 
after copious hemorrhage great numbers of normoblasts ap- 
pear in the circulation, which, however, soon disappear as the 
blood tends to reach the normal. Degenerated cells are 
sometimes found. 

The gross appearance of the blood presents wide variations ; 
it is commonly paler and more fluid ; the specific gravity^is 
generally reduced, the watery elements being increased. The 
alkalinity is never markedly changed, although it is usually 
somewhat diminished. 

Symptoms. — Symptoms depending upon. secondary blood 
changes are not always in evidence and at other times pro- 
nounced. It is evident as the blood becomes impaired that 
either it fails properly to absorb or to carry to the tissues 
nourishment, oxygen, or other materials necessary for metab- 
olism, or it fails to deliver to the excretory organs the waste 
products; definite symptoms therefore arise from the anemia. 
The symptoms produced by the anemia may, however, be 
masked by the disease in question. 

Pallor of the ski?i is one of the signs of symptomatic anemia ; 
but this is very deceptive at times. Pallor of the mucous 
membranes (the conjunctivae and lips) is a more definite indi- 
cation. In rare cases even the pallor of the mucous mem- 
branes is not a definite sign ; an instance of this is leukocy- 
themia. Pallor depends rather upon reduction of hemoglobin 
than of erythrocytes. 

Shortness of breathing and palpitation of the heart are 
constant and important symptoms. The dyspnea upon exer- 
tion is due to the deficiency of hemoglobin, and, in the severer 
forms of anemia, also due to a diseased heart muscle. Palpita- 
tion, like shortness of breath, develops upon the slightest exer- 
tion or the least excitement. Headache, throbbing in the head, 
tinnitus aurium, dizziness, and fainting are often seen, and are 
due to the impoverished blood or insufficient blood supply 
to the brain. Restlessness, peevishness, and irritability of 
temper are common, even delirium, coma, and convulsions may 
occur. Neuralgia is also a symptom, and is due to the poverty 
of the blood. 



6l6 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

In pronounced, long-continued anemia the heart muscle 
tends to become fatty and the chambers dilate, giving rise to 
distinct physical signs. The apex-beat may become displaced 
to the left, and maybe more diffuse, and, on account of palpita- 
tion, it is more forcible, but most often the impulse is weaker 
than normal. With dilatation, relative incompetency of the 
mitral and tricuspid valves may develop. Upon auscultation, 
murmurs may be heard in any area, the one most commonly 
noticed being a soft, systolic, blowing murmur in the pul- 
monary area. A venous hum (bruit de diable, or nun's mur- 
mur) is frequently heard over the veins of the neck. 

Edema, chiefly of the feet, and sometimes of the face and 
hands, is seen only in the profound forms of anemia, and is prob- 
ably to be ascribed to changes in the composition of the blood 
and to cardiac disturbance. If the blood-vessel walls undergo 
fatty change, they are liable to rupture, hemorrhage following. 
This is observed only in extreme forms of secondary anemia, 
more commonly in primary anemia (progressive pernicious 
anemia). Hemorrhage may occur in the skin, subcutaneous 
tissues, and retina, into the serous cavities, and from the 
mucous membranes. 

Digestive symptoms are also present : dyspepsia is com- 
mon ; the appetite is impaired ; the tongue is coated ; the 
bowels are most often constipated, although diarrhea may 
exist. Loss of body- weight is not a symptom of anemia, but 
rather of the underlying disease. It may be said that when 
there is very little or no loss of weight, the anemia in ques- 
tion is of a primary nature, while if the nutrition of the body 
suffers greatly, and there is marked emaciation, the anemia is 
probably secondary. Weakness is pronounced ; febrile attacks, 
known as " anemic fever" or " essential fever of anemia," 
are common. The temperature range may be intermittent, re- 
mittent, or subcontinuous. The urine is commonly paler than 
normal, although much depends upon the underlying cause. 
Menstrual disturbances, especially amenorrhea, are frequent, 
but menorrhagia may be present, and in some cases may be 
the cause of the anemia. The symptoms and signs of rapid 
profuse bleeding are the same as those of shock. 

Prognosis. — This depends upon the underlying cause. 

Treatment. — The treatment should be directed to the cause. 
If due to hemorrhage, measures speedily to control this 
should be instituted. If due to improper or deficient food, 
this should be corrected. In organic disease the underlying 



CHLOROSIS. 617 

condition must first be treated ; there is often little hope for 
cure in these cases. In the infectious diseases the anemia is, 
as a rule, treated in convalescence. When caused by toxic 
substances and animal parasites, these should be, if possible, 
eliminated. The drugs which have proved most efficient are 
iron, arsenic, cod-liver oil, bone-marrow, etc. 



CHLOROSIS. 

Definition. — Chlorosis is a form of primary anemia, affect- 
ing chiefly the female sex at the time of puberty or in early 
womanhood, and characterized by marked oligochromemia. 

Synonyms. — Chloremia ; chloranemia ; green sickness ; 
morbus virgineus. 

Etiology. — This disease almost exclusively affects females, 
rarely, if ever, males. It develops at about the time of pub- 
erty ; occasionally later in life, when it is called "chlorosis 
tarda." The disease is known in all races and every climate. 
Certain occupations predispose to the disease. It is common 
in those closely housed, such as mill girls, school children, 
and those employed in factories or stores. Sedentary habits, 
lack of exercise, fresh air, and sunlight, mental anxiety, change 
of climate, and homesickness also predispose. The city seems 
to be more favorable for its development than the country. 
Heredity seems to play some part in the cause. It is com- 
mon in girls who emigrate. There is a relationship between 
tuberculosis and chlorosis, as girls who have a scrofulous ten- 
dency often become chlorotic. The disease is said by some 
to be more common in blonds, but this is doubtful. There 
are many theories as to the cause. Virchow observed hypo- 
plasia of the arterial system, especially narrowing of the aorta. 
Sir Andrew Clark supposed that it was due to auto-intoxication 
from constipation. Ulceration of the stomach has also been 
suggested as a cause. Pick believed that it was due to the 
absorption of some poisonous substance from a dilated stom- 
ach. Lloyd Jones regards chlorosis as an exaggeration of 
some physiologic condition which occurs in the blood of 
healthy females at the time of puberty, and which shows 
itself in many women at each menstrual period. He also 
observed that it occurred in large families. 

Pathology. — The heart and the arterial system may show 
hypoplasia ; the genital organs may be imperfectly developed. 



6l8 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

The blood, however, shows the most marked pathologic 
changes. 

Pathology of the Blood. — The gross appearance of the 
blood is altered, it being remarkably fluid, flowing freely, and 
it is of a pale red color. There is a tendency to coagulation in 
the blood-vessels, but extravascular coagulation is retarded. 
The alkalinity is slightly increased. The specific gravity 
of the blood is reduced, but the specific gravity of the serum 
is sometimes higher than the normal ; the number of erythro- 
cytes is normal or slightly decreased ; the hemoglobin shows 
a constant marked reduction ; the color-index is constantly 
low. The leukocytes are normal as to number ; however, 
sometimes the lymphocytes are increased at the expense 
of the polynuclear elements. The red blood-cells are under- 
sized, and in extreme cases may show variation in size and 
outline. Nucleated cells are occasionally found, being usually 
of the normoblastic type. A few myelocytes may rarely 
be present. The blood plates are usually increased. 

Symptoms. — The disease is gradual in its onset, the patient 
losing color, complaining of dyspnea, weakness, palpitation of 
the heart, and constipation. In a few instances the color of 
the lips and cheeks is not lost, but is quite high, the term 
chlorosis florida being applied to these cases. The appetite 
becomes perverted ; there is usually a craving for sour food, 
such as pickles, or for sweets ; often school-girls are found 
to be eating chalk. Dyspeptic symptoms are common. As 
the disease progresses the pallor becomes extreme. The 
skin is of a yellow-green color; hence the term ''green 
sickness," or "chlorosis." The green hue is more apparent 
in dark-complexioned than in fair individuals. Extreme 
weakness and giddiness accompany the pallor. In chlorosis 
it is sometimes noticed that there is an absence of horizontal 
folds in the forehead when the patient is suddenly asked to 
look up without raising the head ; this is known as " Joffroy's 
sign." Slight pufifiness or edema of the face, hands, and 
ankles may appear ; the conjunctivae are pale and the sclero- 
tic coat of the eye becomes bluish in color. Menstrual 
disturbances, especially amenorrhea, are common ; occasionally 
there may be slight pyrexia. Loss of flesh is not apparent ; 
in some cases a gain in weight will occur. The respiration is 
quickened ; a rapid heart action will be noticed. 

These symptoms are probably due to the defect of coloring- 
matter in the blood, nature making an effort to carry the 



PERNICIOUS ANEMIA. 619 

hemoglobin rapidly so as to make up for the deficiency in 
the amount, hence giving rise to palpitation, dyspnea, head- 
ache, neuralgia, giddiness, slight edema, etc. The fats are 
probably not oxidized, therefore the weight does not decrease. 
Examination of the heart will most often reveal a soft, sys- 
tolic murmur, heard loudest at the pulmonary area. A sys- 
tolic murmur is sometimes heard over the subclavian artery. 
Over the veins of the neck a continuous murmur is heard, 
called the venous hum, bruit dc diable, or nun's murmur. 

Diagnosis. — The occurrence of the disease in young females 
with digestive, menstrual, and vascular derangements, and the 
blood examination, are necessary to diagnosticate the condi- 
tion. 

Secondary Anemia. — This condition often shows the same 
blood changes, and it is sometimes called chlorotic anemia, 
but the leukocytes are usually increased, Jess commonly 
normal, and rarely decreased. The clinical history is neces- 
sary for diagnosis. 

Prognosis. — This is always favorable unless complications 
develop. 

Treatment. —Rest in bed is important, often bringing about 
a complete recovery without the administration of drugs. 
Fresh air and sunlight are beneficial, and food should be 
nutritious. Iron is indicated and is of great use in the treat- 
ment. Arsenic, bone-marrow, hydrotherapy, and oxygen in- 
halations are sometimes recommended. The patient usually 
recovers in from three to six weeks. 



PERNICIOUS ANEMIA. 

Definition. — This is a primary anemia, characterized by a 
marked decrease in the number of red blood-cells, by fatty 
degeneration of the heart, liver, and kidneys, and by a pecu- 
liar lemon-yellow discoloration of the skin. 

Synonyms. — Progressive pernicious anemia ; idiopathic 
anemia ; essential anemia ; corpuscular anemia ; myelogenic 
anemia. 

Etiology. — Addison, in 1855, described the disease, which 
is sometimes called " Addison's anemia." Most frequently this 
disease affects males. It is most common in middle life. The 
cause has not been determined. Pregnancy and parturition are 
predisposing causes. Atrophy of the gastric tubules has been 
regarded as an etiologic factor. Band suggested that it was 



620 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

due to a lesion of the sympathetic nerves, and termed it 
" ganglionic anemia." The presence of intestinal parasites, 
such as anchylostoma duodenale and the bothriocephalus latus, 
often produces extreme anemia. Occupation and habit do not 
seem to play an important part among the predisposing causes. 

Pathology. — The skin shows a characteristic lemon-yellow 
discoloration. The fats are well preserved and of a light 
yellow color. The spleen may be somewhat enlarged and 
may show pigmentation. The heart, liver, and kidneys reveal 
fatty degeneration and iron pigmentation. The stomach is 
often small and the gastric tubules are atrophied. Hemor- 
rhages may be present in the retina and in other parts of the 
body, such as the skin and the gastro-intestinal and respiratory 
tracts. The bone-marrow almost constantly shows changes, 
becoming softened, reddened, or lymphoid in character. 
Posterior sclerosis of the spinal cord may be present. 

The blood shows marked changes ; it is watery and pale 
red, sometimes resembling weak coffee. It is often difficult 
to procure, as the tissues are almost bloodless. The specific 
gravity is decreased and the coagulation retarded ; the erythro- 
cytes show a marked reduction in their number — in extreme 
cases 500,000, or a count as low as 143,000 to the cubic milli- 
meter has been recorded. Commonly, 1,000,000 to the cubic 
millimeter are found. The hemoglobin is also greatly reduced, 
but the percentage being relatively higher than the colored 
corpuscles, the color-index, therefore, is above the normal. 
The leukocytes are normal or reduced in number. 

Lymphocytosis is quite constant, a few myelocytes usually 
being present. The red blood-cells vary greatly in size, the 
majority of them being somewhat larger than normal, and 
poikilocytosis is marked — more constant than in any other dis- 
ease. Nucleated red cells are found, mostly of the megalo- 
blastic type. Polychromatophilic changes, and occasionally 
shadow corpuscles, are noticed. 

Symptoms. — The disease is very gradual in its onset. The 
patient first notices the extreme pallor, or is informed of it 
by friends. Shortness of breath, weakness, palpitation of 
the heart, giddiness, and headache are early symptoms. After 
some time the weakness becomes extreme, and the patient 
must discontinue work and consult his physician. Often the 
disease is ushered in by gastro-intestinal disturbances, as pro- 
fuse diarrhea and vomiting. Loss of weight is not marked 
or does not occur. A sense of discomfort, which may amount 



LEUKEMIA. 62 1 

to pain, is sometimes experienced in the chest. Hemorrhages 
may occur in the retina, producing disturbances of vision. 
Epistaxis, hemoptysis, or hematemesis is present, especially 
late in the disease. Purpuric symptoms and edema of the face, 
hands, and feet may arise. 

On examination of the patient the skin shows the character- 
istic lemon-yellow discolorations. The heart-sounds are weak 
and hemic murmurs are common. The pulse is weak and 
often irregular. The spleen may be slightly enlarged. The 
symptoms of the disease gradually become more grave, and 
death results ; or, after prolonged treatment, apparent recovery 
may seem to ensue, only to be followed by another relapse, when 
the patient succumbs. Two or three relapses may occur. In 
the course of pernicious anemia fever often develops (termed 
"anemic fever"). Constipation, less commonly diarrhea, is 
present. 

Diagnosis. — The diagnosis is by no means easy, and must 
be made from the history and the blood examination. The 
disease is often mistaken for obscure malignant growths, renal 
disease; and other grave affections. The examination of the 
urine will reveal true kidney lesions. 

Prognosis. — Always grave ; death results in from a few 
months to a few years ; apparent recovery, followed by relapse, 
is common. 

Treatment. — Rest in bed is essential, and easily digested, 
nutritious food should be given. Medicinally, arsenic has been 
found to be of most value, given in the form of Fowler's solu- 
tion, in ascending doses. Patients often bear large amounts. 
If this drug is not well borne, iron may be substituted ; the 
latter, however, has not proved of much service in the treat- 
ment. Bone-marrow is also useful. Stimulants, such as 
strychnin and alcohol, and inhalations of oxygen are of ad- 
vantage. 

LEUKEMIA. 

Definition. — Leukemia is a disease in which the white 
blood-corpuscles are greatly increased in number ; the per- 
centages of the various forms also differ widely from the 
normal. It is characterized anatomically by changes in the 
spleen, lymphatic glands, or bone-marrow, singly or combined. 

Synonym. — Leukocythemia. 

Varieties. — Splenomedullary (or lienomedullary) and lym- 
phatic. 



622 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

Historic Notes. — The disease was first described in 1845, 
by Bennett, as a suppuration of the blood, and very shortly 
afterward Virchow published a case, the condition being ob- 
served independently. The latter also pointed out that the 
numerous white corpuscles found in the blood were leuko- 
cytes, and termed the condition leukemia. 

Etiology. — All races are susceptible, but, according to 
Eichhorst, it is more likely to affect the Jews. It is also 
more frequent in low life than in the upper ranks of society. 
The disease has been found in all parts of the world ; it is, 
however, very rare. 

The splenomedullary variety is more frequent in adults, 
while lymphatic leukemia is said to be more prevalent in 
children. Heredity seems to play some part in the causation. 
Pregnancy and parturition are also factors. According to 
Gowers, 20% of the cases ot leukemia are preceded by mal- 
aria. Syphilis and injury are perhaps predisposing. The 
exciting cause has not been determined. It has been sug- 
gested that it is of an infectious nature. Lowit claims to have 
discovered an ameba in the blood. This is by no means 
settled. 1 

Pathology. — In the splenomedullary variety the spleen is 
found to be tremendously enlarged, weighing ten pounds or 
more. The capsule is thickened and the surface of the organ 
is somewhat irregular. On section, it is very firm, especially 
in advanced cases. The color of the pulp is reddish-brown. 
Infarcts are common. 

This enlargement is due to the proliferative changes of 
the leukocytes, lymphoid tissue, and usually the connective 
tissue. Charcot-Leyden crystals may be found in the organ. 
The bone-marrow changes are the following : The bone- 
marrow of the spongy and long bones becomes altered early 
in the disease — softer, and later almost semiliquid (lymphoid 
or pyoid) ; the fats are also replaced by the proliferation of 
cells. These changes are due to the excessive multiplication 
of nucleated red blood-corpuscles (showing the various stages 
of mitosis), marrow-cells, and giant cells. There are also 
many lymphoid corpuscles. The blood changes are probably 
largely dependent upon the marrow disturbance. The liver 
may be enlarged and may contain collections of leukocytes 
in various parts ; the kidneys may also contain these nodules. 

1 " Ceatralblatt fiir Innere Medicin," No. 19, 1900. 



LEUKEMIA. 623 

Hemorrhages are common in various organs and from the 
skin and mucous surfaces in both types. 

In the lymphatic variety groups of lymph-glands (but not 
necessarily all chains) are enlarged, owing to hyperplasia of 
the lymphoid cells, and the spleen is slightly increased in size. 

Pathology of the Blood. — In the splenomedullary variety 
the gross appearance is altered, occasionally being milky in 
character ; the specific gravity is decreased, the alkalinity is 
somewhat diminished, and coagulation is slightly retarded. The 
erythrocytes usually show a slight reduction in number, occa- 
sionally being normal ; and in some cases, especially those of 
long standing, a marked decrease is present. The hemoglobin 
is diminished somewhat more than the percentage of red cells. 
The color-index is usually below normal. The leukocytes 
show an enormous increase in the ordinary case — from 250,000 
to 400,000 or more. In extreme cases the colorless blood- 
cells almost equal the number of erythrocytes. The estimation 
of hemoglobin by the color test is sometimes difficult, on 
account of the milky appearance of the blood (due to the 
increased number of leukocytes). An examination of the 
stained films will reveal large numbers of myelocytes, compos- 
ing from 30^ to 50% of all the leukocytes. Finely granular 
basophilic cells are met with, and some have observed mast- 
cells (coarsely granular basophilic cells). Nucleated red 
blood-cells, usually of the normoblastic type, are more fre- 
quent in this variety of leukemia than in any other known 
condition, and poikilocytosis and degenerative changes may 
also be found. 

In the lymphatic variety the gross appearance of the blood 
may show very slight change, or may resemble the variety just 
described. Oligocythemia and oligochromemia are more pro- 
nounced than in the splenomedullary form. The leukocytes 
show a marked increase, from 50,000 to 200,000, but not to 
the extent found in the splenomedullary type. Examination 
of the stained films reveals an enormous increase in the lymph- 
ocytes ; in some cases the larger forms predominate, in others 
the smaller. They usually constitute the greater proportion 
of the leukocytes, sometimes as high as from 97 <f to 98 J&. 
A very few myelocytes and nucleated red blood-cells are 
rarely met with. 

Symptoms. — The onset of this disease is insidious, although 
acute varieties are found which last from a week to three 
months, ending fatally. 



624 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

The early symptoms are weakness and loss of weight. In 
some cases there is marked anemia, but in others this symp- 
tom is completely absent. 

In the splenomedullary variety fullness and a sense of dis- 
comfort in the abdomen will be noticed. Gastro-intestinal 
disturbances may arise, probably from pressure. Patients 
have consulted physicians for dyspeptic complaints when suf- 
fering from leukemia. 

In the lymphatic type the glands become enlarged, affecting 
chiefly those of the neck, the axilla, and the inguinal region. 
This enlargement is pronounced or slight, and the spleen is 
but little increased in size. Shortness of breath will develop 
as the disease progresses ; edema of the feet, ankles, face, and 
hands will appear in advanced stages ; irregular fever and 
dimness of vision may arise. 

In the splenomedullary variety tenderness over the bones — 
such as the long bones of the extremities, the sternum, and 
the ribs — develops in many cases. On examining the patient, 
in the splenomedullary variety, the spleen is found to be 
greatly enlarged, distending the abdomen, widening the base 
of the chest, and, indeed, in some cases apparently filling 
the entire abdominal cavity, so that it reaches to the right 
anterior superior spine of the ilium. The heart is displaced 
upward. The liver in many cases is enlarged, the lower border 
of liver dullness extending far beneath the costal margin. The 
urine is commonly slightly albuminous, and may contain 
blood. The general appearance of the patient usually indi- 
cates anemia, but there are cases apparently quite robust, 
termed "leukemia plethora." In the lymphatic variety the 
anemia is always more pronounced. Hemic murmurs may 
be present in both these varieties, but are more likely to occur 
in the lymphatic forms. Purpuric manifestations and hemor- 
rhages may also occur. 

Splenomedullary leukemia, which is the most common type, 
usually runs a course of from one to three years. Treatment 
may have a distinct beneficial effect, the patient gaining strength, 
the spleen diminishing in size, and the leukocytes decreasing in 
numbers, in some cases reaching the normal. The condition 
invariably returns, and death results usually after a number 
of relapses. 

Diagnosis. — The direct diagnosis depends upon the enlarge- 
ment of the spleen or lymphatic glands and upon the charac- 
teristic blood changes. Indeed, in the splenomedullary variety 



hodgkin's disease. 625' 

the blood picture is typical ; the great number of leukocytes — 
a large percentage of these being myelocytes — and many 
nucleated red blood-cells revealing the condition. In the 
lymphatic form an increase in the lymphocytes and an almost 
entire absence of myelocytes and nucleated red blood-cells are 
conspicuous. 

Hodgkin's disease may be differentiated from leukemia by an 
absence of the enormous increase in the number of leukocytes 
and by the slight, if any, enlargement of the spleen. Splenic 
tumors are easily differentiated by an examination of the blood. 

Prognosis. — This is very unfavorable, death generally 
resulting in from one to three years in the chronic form 
and in from a few weeks to three months in the acute. 

Treatment. — Rest in bed is desirable and a nutritious diet 
should be given. Arsenic should be administered early, pref- 
erably in the form of Fowler's solution, the dose being in- 
creased to the point of tolerance ; this drug seems to have a 
marked beneficial effect. The treatment must be continued in 
order to hold the disease in check, but after a time, in spite 
of treatment, the condition of the patient will grow worse. 
The discontinuance of treatment will cause a return of the 
symptoms. It should always be remembered that arsen- 
ical pigmentation of the skin develops after prolonged admin- 
istration of this drug. Ergot has been recommended ; bone- 
marrow and iron are also found to be useful, especially when 
arsenic is not well borne. Oxygen inhalations may be bene- 
ficial. 

HODGKIN'S DISEASE. 

Definition. — This is a progressive disease, characterized by 
hyperplasia of the lymphatic glands, at first local, then be- 
coming general, accompanied by loss of weight, weakness, 
and anemia. 

Synonyms. — Pseudoleukemia ; lymphadenoma ; adenie ; 
malignant lymphoma ; lymphatic anemia. 

Etiology. — The disease was described by Hodgkin in 1832. 
This is a rare disease. It occurs most frequently before 
the age of forty ; males are more susceptible than females in 
the ratio of 3 to 1. Mental anxiety, ill health, and poor 
nutriment seem to play some part as predisposing causes. 
Malaria, rickets, and syphilis also appear to predispose. The 
exciting cause has not been determined ; it is, no doubt, some 
irritant which causes the proliferation of the lymphoid elements. 
40 



626 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

Pathology. — The enlargement of the lymphatics is at first 
local, and often supeificial, affecting most frequently the ante- 
rior or posterior cervical chains on one side. The axillary 
glands are sometimes first enlarged, and more rarely the 
inguinal. The intrathoracic or abdominal gland may some- 
times be the primary seat. The condition remains local for 
some time, then, becoming general, the remaining lymphatic 
glands become enlarged, being those of the mediastinum, 
posterior peritoneal and mesenteric glands, etc. Early the 
glands are slightly enlarged, are freely movable, and are 
separated from one another ; later they greatly increase, often 
reaching the size of a cocoanut ; they may become adherent 
to one another. 

As the disease progresses and lymphoid deposits begin to 
appear in many organs, the spleen, being most commonly 
affected, is enlarged as a result. The glands may be either 
hard or soft ; they rarely, if ever, caseate or ulcerate, and when 
this does occur, it is limited and very slight, and had better 
be considered an associated or secondary manifestation. The 
bone-marrow usually becomes lymphoid in character. 

Microscopic examination of the glands reveals proliferation 
of the lymphoid elements ; the interstitial substance is marked 
in some cases, causing a hard condition of the glands, while 
this is almost entirely absent in others. 

According to Bramwell, "it is important to note that, 
although in typical cases of Hodgkin's disease the glandular 
enlargements present the pathologic characters which have 
just been described, in some cases in which the glandular 
enlargements during life present all the characteristic clinical 
features of Hodgkin's disease, the enlarged glands are found 
after death to.be caseous and tubercular.'' He further adds : 
" I have seen several cases of this kind, and I have been so 
impressed with the difficulty there is in some cases, more 
especially in children and in young subjects, of differentiating 
during life the glandular enlargement due to Hodgkin's dis- 
ease from that due to tubercle, that I now have great hesitation 
in committing myself to a definite diagnosis of Hodgkin's 
disease and in excluding tubercle, unless the spleen is dis- 
tinctly enlarged, or unless there is evidence of the presence of 
lymphoid deposits in other organs and tissues." 

The Blood. — The anemia in Hodgkin's disease is commonly 
of the chlorotic type, mild in the beginning and severe toward 
the end of the disease. Poikilocytosis and nucleation of the red 



hodgkin's disease. 627 

blood-cells may occur in extreme degrees of anemia. The 
leukocytes are usually normal ; they may be slightly increased 
or decreased. It is common to see a slight increase in the 
percentage of the polynuclear elements, rarely in the lympho- 
cytes. It is claimed by some that pseudoleukemia terminates 
in leukocythemia. 

Symptoms. — The onset is insidious, and usually pursues a 
long-continued course, rarely an acute one. Weakness be- 
gins to show itself, the glandular enlargement appears, emacia- 
tion soon follows, and anemia also develops. Palpitation of 
the heart may arise as a result of the anemia. There is loss 
of appetite, arising from the impaired nutrition. Very soon in 
the course of the disease fever, irregular or hectic in type, 
develops. The glandular enlargement most frequently affects 
the cervical chain, either the anterior or the posterior, unilat- 
eral or bilateral. These glands are freely movable and pain- 
less, and present no signs of acute inflammation. They 
increase in size, becoming somewhat fused together, and rarely 
soften and suppurate. This enlargement may be local for some 
time, — indeed, for a year or more, — then it spreads to the axil- 
lary, inguinal, retroperitoneal, bronchial, mediastinal, and mes- 
enteric glands. The enlargement in many instances is extreme, 
so that it becomes impossible for the patient to place the 
arm alongside the body or to draw the head down upon the 
chest. In 7S% of the cases, according to Gowers, the spleen 
will become slightly enlarged, so that it might be readily pal- 
pated. Pressure symptoms might arise at any time from 
the glandular enlargement. Toward the end of the disease 
profound anemia and cachexia appear. Weakness and emacia- 
tion are marked and hemic murmurs are to be heard over the 
heart. Loss of appetite and dyspeptic symptoms usually indi- 
cate lymphoid deposits in some part of the gastro-intestinal 
tract. 

The course of the disease is, as a rule, chronic, lasting from 
one to three years, death almost invariably occurring, either 
as a result of the gradual failure of the vital powers or from 
pressure symptoms upon the bronchus, the trachea, the 
larynx, or the esophagus. Cases may terminate from inter- 
current complications. 

Diagnosis. — The diagnosis of Hodgkin's disease is difficult 
in the early stages, but less so when the disease is fully 
developed. The general glandular enlargement, commonly 
accompanied by increase in the size of the spleen and by 



628 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

severe anemia, is characteristic. A blood examination is 
necessary to differentiate it from leukocythemia. 

Differential Diagnosis. — Hodgkin's disease is often with 
difficulty differentiated from tubercular adenitis. Tuberculosis 
often affects the glands of the neck, especially those of 
the submaxillary chain, most frequently unilateral, and show- 
ing a distinct tendency to softening and breaking down. Early 
life predisposes to, and tuberculosis of the lungs often accom- 
panies, the condition. The glandular enlargement persists for 
a long time and shows no tendency to become general, while 
in Hodgkin's disease the reverse is true. The enlarged 
glands may, however, fuse together, somewhat resembling 
tubercular adenitis, but do not show a tendency to break 
down or to caseate. The blood will not show distinct points 
of differentiation between these two conditions. 

The differential diagnosis of Hodgkin's disease from sarcoma 
of the lymphatic glands is often impossible, especially in the 
early stages. Sarcoma spreads by means of the blood currents, 
thus causing the growth to arise in almost any part of the 
body, very often quite remote from the original seat, while in 
Hodgkin's disease the enlargement spreads and seems to follow 
the course of the lymphatic glands more or less closely. The 
blood may at times show points of differentiation — a leukocy- 
tosis of from 20,000 to 50,000 is suggestive of sarcoma ; but 
if this does not exist, it is quite impossible to show any point of 
importance from the blood examination. Again, the spleen is 
usually enlarged in Hodgkin's disease, while it is not in sarcoma. 

Carcinomata of the lymphatic glands may be differentiated 
from Hodgkin's disease by the following : The glands are 
always secondarily involved, and the primary seat of the new 
growth will give the characteristic symptoms, depending upon 
the locality. The splenic enlargement does not usually exist, 
and the disease is most frequent after middle life. 

The differentiation of Hodgkin's disease from lymphatic and 
splenomedullary leukemia is made by examination of the blood. 

Prognosis. — The prognosis-is grave. 

Treatment. — If the condition is diagnosticated early, sur- 
gical interference may be tried. Medicinal treatment is of 
very little avail, arsenic being the only drug which seems to 
retard the disease somewhat. It should be given in the form 
of Fowler's solution, well diluted, in ascending doses, until the 
physiologic point is reached. Tonics, such as cod-liver oil, 
quinin, and iron, will be found beneficial. 



SPLENIC ANEMIA. 629 



SPLENIC ANEMIA. 

Definition. — This is a disease characterized by enlargement 
of the spleen and by marked anemia of the chlorotic type, 
without increase in the number of leukocytes, and always ter- 
minating fatally. 

Synonyms. — Splenic pseudoleukemia ; splenic cachexia ; 
lymphadenoma splenicum. 

Etiology. — Little is known of the etiology, and some still 
question the clinical identity of this disease. It was described 
by Banti, in 1882, and is sometimes known as Band's disease. 
The disease is very rare ; males are affected more often than 
females in the proportion of 4 to 1, in adult life between the 
ages of twenty and fifty. 

Pathology. — Emaciation is not marked, the bodily fats 
being well preserved. The spleen is enlarged, in some in- 
stances weighing as much as seven pounds. Its consistence is 
firm and its color reddish-brown ; the splenic capsule is some- 
times thickened. Infarcts have been noted in the organ. Upon 
microscopic examination it is found that the fibrous connec- 
tive tissue is greatly increased and that many of the Malpighian 
bodies are replaced by the cicatricial tissues. The splenic 
pulp is much reduced. In short, the organ is in an atrophic 
state. The liver is sometimes slightly enlarged, and shows 
beginning cirrhotic change. The bone- marrow and the lymph- 
atic glands are normal. Hemorrhages are sometimes found 
in various parts of the body. The blood reveals an extensive 
reduction in the number of erythrocytes, but always a more 
marked decrease in the hemoglobin, hence a low color-index 
(chlorotic type). The leukocytes show no absolute increase, 
but when complications are present, they may be slightly in- 
creased. A relative lymphocytosis has been encountered. 
The red blood-cells may show nucleated forms and some 
degree of poikilocytosis. 

Symptoms. — The onset is insidious, and is marked by 
symptoms which are referable to anemia, such as shortness of 
breath, palpitation of the heart, dizziness, considerable loss of 
appetite, nausea, vomiting, and constipation, although in some 
instances diarrhea is present. Hemorrhages from the mucous 
membranes and into the tissues may be observed. Later, the 
spleen becomes enlarged, the organ may extend beyond the 
median line below the level of the umbilicus, and pain in 
this region is common, being due to secondary involvement 



63O DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

of either the pleura or the peritoneum. Irregular fever (anemic 
fever) usually accompanies the disease. The heart shows 
some degree of dilatation, and hemic murmurs are usually 
heard. The course of the disease may be interrupted by a 
temporary arrest of the symptoms, but very soon a relapse 
takes place ; the entire duration varies from six months to two 
years. Instances are on record where the disease has lasted 
as long as four and a half years. 

Diagnosis. — This depends upon the enlargement of the 
spleen and upon the examination of the blood. Pernicious 
anemia is distinguished from this disease by the absence of great 
enlargement of the spleen and by the blood examination. In 
Hodgkin's disease the lymphatic glands are involved. In spleno- 
medullary leukemia the blood examination is sufficient for diag- 
nosis. The enlargement of the spleen due to atrophic cirrho- 
sis of the liver is distinguished from this condition by the other 
signs of portal congestion (ascites, hemorrhoids, etc.). The 
enlargement of the spleen in malaria is easily diagnosticated 
on account of the presence of the plasmodium in the blood. 

Prognosis. — The prognosis is hopeless. 

Treatment. — The treatment is that of other pronounced 
anemias, but no remedy is on record which has a decided 
effect. 

ADDISON'S DISEASE. 

Definition. — -A disease characterized by asthenia, feebleness 
of the heart action, nausea, vomiting, and bronzing of the skin 
and sometimes of the mucous membranes, associated with 
lesion of the suprarenal capsules. 

Synonyms. — Morbus Addisonii ; melasma suprarenale ; 
bronzed-skin disease. 

Etiology. — This disease was described by Dr. Addison, in 
1849. It is most common between the ages of twenty and 
forty; it is rare in early or in advanced periods of life. It is 
more prevalent in males. Blows and injuries to the back 
occasionally seem to be exciting causes. The disease is 
almost constantly associated with tubercular lesions of the 
suprarenal bodies. 

Pathology. — The lesion is usually bilateral, occasionally 
unilateral. Rarely no lesion of the adrenals will be found. 
In a large number of the cases both suprarenal bodies are 
tubercular and enlarged, although occasionally smaller than 
normal. They are firm and nodulated, irregular in outline, 



addison's disease. 631 

and show the characteristic caseous necrosis of tuberculosis. 
Interstitial change, showing a preponderance of fibrous connec- 
tive tissue, sometimes exists. Simple atrophy and sclerotic and 
fatty changes of the adrenals have been found in connection 
with the disease, and occasionally the entire organ may be re- 
placed by fat. These lesions seem to excite inflammatory 
induration in the sympathetic nerve plexus around the organ, 
in this way affecting the semilunar ganglion. The latter 
changes, however, are not constant. Carcinoma and sarcoma 
of the suprarenal capsules may rarely be associated with 
Addison's disease. 

Some authors favor the nervous theory : that the symptoms 
are due to disturbances of the abdominal sympathetic nerves ; 
while many hold the view that the manifestations of the dis- 
ease are due to insufficient secretion of the suprarenal bodies. 
Bramwell notes on theoretic grounds that the symptoms of 
Addison's disease are partly due to the destruction of the cap- 
sules and partly to secondary disturbances in the nerves that 
surround and are in connection with the suprarenal bodies ; 
and he sees no reason why any lesion of the capsules, pro- 
vided only that it is sufficiently destructive, sufficiently chronic, 
and, perhaps, sufficiently irritative in character, may not pro- 
duce the symptoms of Addison's disease. 

Unilateral disease of the suprarenal capsules, tuberculous or 
otherwise, may not necessarily give rise to the clinical mani- 
festations. When the symptoms are present and only one of 
the organs is diseased, there is probably some implication of 
the nerve structure surrounding it. The skin discoloration 
appears to be an accumulation of the normal pigmentation. 
The cells of the stratum Malpighii contain the pigment. The 
spleen is occasionally enlarged. The heart may present marked 
atrophy. 

Symptoms. — The disease is insidious in its onset, and is 
early characterized by asthenia and by feebleness of the heart's 
action, the skin pigmentation generally following these symp- 
toms, but occasionally it is the first sign. The asthenia seems 
to be the result of the lesion of the suprarenal bodies. As 
the disease progresses, weakness of both mind and body be- 
comes extreme. Shortness of breath and palpitation of the 
heart are early symptoms. The heart-sounds and the pulse 
are weak in nearly all cases. Symptoms of exhaustion and 
depression may arise, especially on slight exertion. The 
disease is of a chronic nature. Later the palpitation of the 



632 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

heart and shortness of breath become extreme, and fainting - , 
disturbances of vision, and cerebral symptoms are liable to 
arise. Irritability of the stomach, retching, nausea, and vom- 
iting- are symptoms of importance, due to the asthenia. The 
bowels are usually constipated. Pain may be present in the 
small of the back and in the abdomen. 

Pigmentation of the skin and mucous membranes is the most 
striking and important sign. 

This develops gradually, and usually progresses as consti- 
tutional symptoms increase. The discoloration is first of a 
light bronzed color, and becomes deeper as the disease ad- 
vances. The pigmentation is usually most marked in regions 
of the body where normal pigmentation is prominent, as the 
areola of the nipple, around the genital organs, in the axillae, 
in the groins, upon the backs of the hands, and around the 
umbilicus. 

Late in its course the entire body may be of a uniform 
bronzed color, giving the patient the appearance of a mulatto. 
The mucous membranes, especially those of the gums, lips, 
and tongue, frequently show pigmentation. In rare instances 
the pigmentation may be absent, but the other characteristic 
symptoms are present. 

Emaciation is not a marked symptom, and is usually slight. 
The temperature range, as a rule, is normal or subnormal 
during its course. The anemia develops gradually, there 
being a decided decrease in the number of erythrocytes and 
in the percentage of hemoglobin, or the latter may show a 
greater reduction than the corpuscles, producing the chlorotic 
type of anemia. The white blood-cells are, as a rule, normal. 
The urine may present changes, but they are not character- 
istic. 

The disease terminates fatally, either from asthenia, or, in 
some instances, the patient sinks into the " typhoid state." 

Diagnosis. — The diagnosis, as a rule, is easy. The asthenia, 
weakness of the heart, vomiting, the presence of anemia with- 
out marked emaciation, and the pigmentation of the skin — 
easily warrant a positive diagnosis. In atypical cases, when 
pigmentation is slight or absent, or in those cases which are 
early marked by pigmentation without constitutional symp- 
toms, the diagnosis is difficult or impossible. 

Differential Diagnosis. — Various diseases may mislead 
one's diagnosis, such as vagabond's discoloration of the 
skin, due to pediculi. Chronic pulmonary tuberculosis may 



SCURVY. 633 

be associated with pigmentation of the skin. Nitrate of silver 
discoloration is usually darker, and is associated with the treat- 
ment bv this drug which has been long administered. Ar- 
senical discoloration may be distinguished by a general 
mottling- associated with the long-continued administration of 
arsenic, very frequently seen in cases of leukemia. The pig- 
mentation sometimes seen in malaria, especially in the cachectic 
form, and in scurvy, pregnane}*, syphilis, malignant diseases, 
and exophthalmic goiter is, as a rule, readily distinguished 
from that of Addison's disease. Chronic peritonitis and sun- 
burn may also be easily rcognized, as the constitutional 
symptoms are absent. Pernicious anemia may be differentiated 
from Addison's disease, as the skin discoloration is lemon- 
yellow, and also by examination of the blood. Hypertrophic 
cirrhosis of the liver causes a deep yellow discoloration, but 
this should not be mistaken for Addison's disease, as the 
liver is tremendously enlarged and the disease is associated 
with other symptoms of jaundice. 

Prognosis. — The prognosis is grave, death resulting in 
about two years. 

Treatment. — The treatment consists in rest and in avoid- 
ance o£ overexertion and of mental emotions. The diet should 
be light, nutritious, and should consist principally of milk, 
white meats, and eggs. Alcoholic stimulants may be of use. 
Cod-liver oil, iron, and strychnin are also of use. Extract of 
suprarenal capsule has, in a very few instances, been found 
valuable in the treatment of this disease. 



SCURVY. 

Definition. — Scurvy is an affection characterized by anemia, 
by swollen, tender, and bleeding gums, by manifestations of 
purpura, and by great prostration, due to improper food. 

Synonym. — Scorbutus. 

Etiology. — The disease was very common in former times, 
occurring particularly among sailors during long voyages, the 
cause being lack of fresh vegetables and of proper food. Since 
the introduction of steam in navigation the disease has become 
extremely rare. The exciting cause is undoubtedly faulty diet, 
the principal errors being an excess of salt meat and fish, the 
use of stale and tainted food, and the lack of fresh vegetables, 
fruits, and so on. It is probable that the antiscorbutic ele- 



634 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

ments are the potash and some of the organic acids. All ages 
are susceptible, not even infancy being exempt Some condi- 
tions predispose to scurvy, such as anemia, inanition, chronic 
intestinal disease, dysentery, chronic malaria, alcoholism, and 
syphilis. The disease is rare in this country, but is common 
in certain parts of Russia. It occurs in times of famine and 
during long sieges. Scurvy is regarded by some as an infec- 
tious disease, but no positive evidence confirms this view. 

Pathology. — The most constant lesions are those found in 
association with the gums, these being softened and ulcerated, 
with hemorrhages into the tissues, and in severe cases the teeth 
become loosened and fall out. Hemorrhages are encoun- 
tered in many mucous membranes also. Ulcers sometimes 
appear in the ileum and in the colon. The skin, the joints, 
the kidneys, the serous membranes, or the muscles may be 
the seat of blood extravasations, and some of the internal 
organs may reveal granular degeneration. The blood shows 
no distinctive changes except those of anemia. 

Symptoms. — The disease comes on insidiously ; rarely is 
the onset acute. As a rule, there is a history of prolonged 
prostration, anorexia, and lassitude, the gums finally becoming 
sore, soft, and spongy, and bleeding readily. The teeth be- 
come loosened, and in severe cases drop out. Ulceration of 
the gums develops and ecchymosis appears. The breath 
becomes foul and offensive and the tongue may be swollen. 
There may be free bleeding from some of the mucous mem- 
branes, and epistaxis is common. Hemoptysis, hematemesis, 
hematuria, and enterorrhagia may sometimes occur. Extreme 
anemia and some edema, especially of the ankles, are common. 
The soreness of the gums renders mastication difficult. There 
are increasing weakness, palpitation of the heart, emaciation, 
mental depression, Usually impairment of appetite, and consti- 
pation, although sometimes diarrhea is encountered. The 
joints may become swollen and painful. Fever is common 
when the disease is far advanced, but in the early stages a 
normal or subnormal range of temperature is encountered. 

Diagnosis. — In the greater number of cases the diagnosis 
is easy. Many individuals are usually affected at the same 
time, and there is a history of improper food. In single cases 
the disease may be confounded with some of the arthritic 
varieties of purpura, but the previous history, and the rapid 
improvement when suitable food is taken, render the diagnosis 
easy. 



SCURVY. 635 

Prognosis. — In the main the prognosis is favorable. 

Treatment. — A sufficient quantity of anti-scorbutic food 
should always be kept on shipboard as a prophylactic measure. 
The treatment of this disease consists in the use of antiseptic 
mouth-washes, such as dilute carbolic acid solutions, perman- 
ganate of potash, and nitrate of silver. The diet should con- 
sist of plenty of fresh vegetables. Lemon -juice and bitter 
tonics are also of great use. 

INFANTILE SCURVY. 

Synonym. — Barlow's disease. 

Etiology. — This disease most often appears in infants be- 
tween the ages of nine months and fourteen months ; rarely is 
it met with later than the second year of life. It is generally 
believed that the disease is due to improper feeding — the exclu- 
sive use of condensed milk and of various proprietary foods. 
Sometimes cows' milk and sterilized milk are said to be the 
cause of this disease. It occurs in the children of the well- 
to-do oftener than in the children of the poor, for the reason 
that proprietary articles of food are more generally used among 
the former. According to Barlow, the child that is being 
suckled at the breast never develops the disease. 

Pathology. — Subperiosteal hemorrhages causing separation 
of the periosteum are found, the blood finding its way between 
the epiphysis and the shaft of the bone. The legs are most 
frequently affected ; the bones of the arms, the scapula, and the 
lumbar vertebrae may also be the seat of hemorrhages ; later, 
the long bones will reveal marked thickening. The mucous 
membrane of the gums also becomes spongy. 

Symptoms. — The infant grows weak, irritable, fretful, and 
loses appetite. Upon being handled or when the extremi- 
ties are moved, pain is produced. The lower limbs are motion- 
less (pseudoparalysis), the child dreading the pain which is 
produced by movements. Ulceration of the gums, extravasa- 
tion of blood into the tissues, and bleeding from the mucous 
membranes maybe encountered. There is usually some fever, 
although the temperature is rarely above 102 F. Rickets and 
infantile scurvy may coexist. Diarrhea is most commonly 
met with. 

Prognosis. — As a rule, recovery is prompt, unless the dis- 
ease is very far advanced. 

Treatment. — Proper articles of food should be substituted 
for any of the proprietary articles. Fresh cows' milk and 



636 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

meat -juice should be given in proper amounts. Orange- or 
lemon-juice is also beneficial. Proper hygienic surroundings 
and change of climate are indicated. 



PURPURA. 

Definition. — A condition, occurring in many diseases, char- 
acterized by extravasation of blood into the skin, mucous 
membranes, and internarorgans, and sometimes by free hemor- 
rhage from mucous membranes. 

The alterations in the composition of the blood in purpura 
are, generally speaking, those of symptomatic anemia from 
hemorrhage. 

Synonym.— Hemorrhagic diathesis (this term includes 
hemophilia). 

Varieties. — (1) Symptomatic purpura; (2) arthritic pur- 
pura; (j£) purpura hcemorrhagica. 

SYMPTOMATIC PURPURA. 

Infectious. — This is due to a variety of infective diseases, 
such as pyemia, septicemia, typhus fever, smallpox, scarlet 
fever, malaria, measles, and infectious endocarditis. The ex- 
travasation of the blood may be quite large, when it is called 
an ecchymosis ; or pin-points, when it is called petechial. 

Toxic. — Purpura may result from the administration of cer- 
tain drugs, such as potassium iodid, ergot, mercury, bella- 
donna, phosphorus, salicylic acid, and quinin. It has also 
been noticed from the virus of snakes. 

Cachectic. — Various constitutional affections produce pur- 
puric eruptions, such as leukemia, pernicious anemia, tubercu- 
losis, Hodgkin's disease, Bright's disease, scurvy, and cancer. 
This may also be sometimes noticed in advancing years. The 
eruption is confined to the extremities, the wrists, the hands, 
and the legs. 

Neurotic. — This occurs from lesions of the spinal cord, 
such as transverse myelitis, locomotor ataxia, and sometimes 
in hysteria and neuralgia. 

Mechanical. — This form results from trauma, and in asthma, 
whooping-cough, and epilepsy. 



PURPURA. 637 



ARTHRITIC PURPURA. 

Under this term is considered a form of purpura which 
involves the joints and is sometimes spoken of as rheumatic. 
There are, however, no evidences of rheumatic manifestations. 

Purpura Simplex. — This variety is most commonly met 
with in children. It is a mild condition, accompanied by pur- 
puric spots upon the extremities, and sometimes upon the 
trunk and arms, with impairment of the appetite and diarrhea. 

Purpura Rheumatica. — Synonyms. — Miosis rheumatica ; 
Schonlein's disease. (By many this condition is regarded as 
being rheumatic. It is sometimes preceded by sore throat.) 

A condition which attacks both sexes with about equal 
frequency, most commonly in early life, between the ages of 
ten and forty. The joints, especially those of the lower ex- 
tremities, are involved, many simultaneously. The disease is 
characterized by purpuric eruptions, which appear in crops, 
and by fever and articular pains. The eruption is commonly 
limited to the extremities and is bilateral ; in severe cases the 
face and body may be involved. The fever is usually not high. 
Very rarely does it terminate fatally. 

Diagnosis. — The diagnosis depends upon the involvement 
of the joints, many being affected simultaneously with purpura. 

Henoch's Purpura. — It occurs most often in childhood, 
but sometimes in adults. A condition characterized by joint 
involvements, the joints being painful and swollen. Hemor- 
rhages from the mucous membranes, gastro-intestinal distur- 
bances, purpuric manifestations, and a tendency to relapse are 
also characteristic. It is most common in the young. The 
spleen is sometimes enlarged. 

The prognosis is favorable. 

PURPURA HAEMORRHAGICA. 

Synonym. — Morbus maculosus Werlhofii. 

This condition is frequently met with in the young, females 
being more susceptible than males. It is characterized by 
severe hemorrhages from the mucous membranes and by 
cutaneous extravasation. There is marked weakness, and, as 
a result of the hemorrhage, — which may take place from the 
respiratory mucous membranes, from the genito-urinary tract, 
or from the gastro-intestinal mucous membrane, — secon- 
dary anemia develops, which is frequently pronounced, and 



638 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

death may result from loss of bipod. Fever is generally 
present. 

Hemorrhages into the skin are usually pronounced, being 
ecchymotic as well as petechial. 

Diagnosis. — The diagnosis depends upon the rapid onset, 
the profound hemorrhage, the purpuric manifestations, and 
rapidly developing anemia. The condition may or may not 
be accompanied by fever. 

Scurvy is diagnosticated from this condition by the pres- 
ence of swelling and by tenderness of the gums and the his- 
tory of the onset. 

Treatment. — The cause, if possible, should be removed 
when dealing with symptomatic purpura. Tonics, such as 
arsenic, in the form of Fowler's solution, in ascending doses 
until the physiologic limit is reached, may be useful. 

In dealing with free hemorrhages, such as are met with in 
purpura haemorrhagica, the following ways may be of use 
in controlling it : Rest, compression, cold, ergot, tannic 
and gallic acids, acetate of lead, calcium chlorid, gelatin 
or collodion applied to the bleeding surface, or extract of 
suprarenal capsule. An attempt should be made to increase 
the coagulability of the blood and to restore it to its normal 
condition. If the hemorrhage is from a free surface that is 
easy of access, as the mucous membrane of the mouth or nose, 
the application of normal blood to the bleeding surface may 
be found of use. 



HEMOPHILIA. 

Definition. — A disease characterized by a tendency to 
hemorrhage, which is often uncontrollable, and is due to 
a deficiency in the coagulability of the blood. The coagula- 
tion is retarded, and frequently in this condition the blood 
does not coagulate in less than from thirty to fifty minutes. 

Etiology. — There is a marked hereditary tendency, the 
disease being transmitted through the mother (who is rarely 
a bleeder herself, but the daughter of one) to the males 
of the family. The disease is not transmitted through the 
male offspring. Males are very susceptible, in the propor- 
tion of 13 to 1 , and by some t it is believed that the dis- 
ease does not affect females. The condition manifests itself 
most frequently in early life, but sometimes not until early 
adult or middle life. 



HEMOPHILIA. 639 

Pathology. — Coagulation of the blood is delayed. The 
bleeding, when it occurs, is of a capillary nature, there being 
constant oozing. It may take place from a free surface or 
into the tissues. 

Symptoms. — The bleeding frequently results from trifling 
wounds, scratches, extraction of a tooth, or slight operations ; 
or, again, it may occur without trauma from the mucous mem- 
branes or into the tissues. The most common form of bleed- 
ing is from the nasal mucous membrane (epistaxis). It also 
occurs from the mouth, stomach, lungs, kidneys, and urethra, 
and from various parts of the skin. Bleeding frequently takes 
place into the serous sacs, especially about the joints. Death 
may follow in a few hours or the hemorrhage may be pro- 
longed over a period of weeks ; in the latter instance the 
symptoms depending upon anemia manifest themselves. 

Diagnosis. — The diagnosis depends upon the occurrence of 
uncontrollable bleeding in males, — either spontaneous or 
traumatic, the hemorrhage frequently recurring, — the history 
of the disease in some members of the family, and the 
peculiar mode of transmission. 

Prognosis. — As age advances the prognosis becomes more 
favorable. There are some instances in which the tendency is 
outlived. 

Treatment. — Prophylaxis. — Wounds should be avoided as 
much as possible, such as surgical operations, and it should 
also be remembered that the common practice of routine blood 
examination will be interfered with in this disease, and it is a 
good rule, before making a blood examination, always to ask 
whether the person is a " bleeder" or if there is a family his- 
tory of such a disease. 

When the bleeding is from a free surface and easy of access, 
compression and bodily rest may be tried. The local appli- 
cation of ice is often of value. Calcium chlorid and per- 
chlorid of iron are recommended by many. Gelatin, collodion, 
and extract of suprarenal capsule may be found useful, being 
applied directly to the bleeding surface. Freshly drawn blood 
from a healthy individual may be employed as an application. 
The secondary anemia which follows should be treated with 
iron and arsenic. 



64O DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



MYXEDEMA* 

Definition. — A disease characterized by myxomatous 
change of the subcutaneous tissues, due to pathologic lesions 
in the thyroid gland causing diminished or absent secretion. 

Synonym. — Athyrea. 

Varieties. — Three varieties of this disease have been found : 
(a) Myxedema, or adult myxedema ; (b) sporadic cretinism ; 
{/) operative myxedema, or cachexia strumipriva. 

ADULT MYXEDEMA. 

Etiology. — The disease is common in England, also in 
certain parts of Switzerland, but is less frequently found in 
America and other parts of the world. The disease occurs 
more frequently in women than in men, in the proportion 
of 6 to 1. Pregnancy seems to predispose, and it is more 
common in married women, especially those who have borne 
children. The disease is most often encountered between the 
ages of thirty-five and forty-five. Heredity plays a very slight 
part. Exophthalmic goiter seems to bear some relation to the 
disease, as individuals suffering from myxedema frequently 
have brothers or sisters who suffer from exophthalmic goiter. 
Exposure, mental strain, and hemorrhage also seem to pre- 
dispose. 

Pathology. — The thyroid gland shows constant lesions, in 
many instances being degenerated or atrophied. The gland is 
usually smaller than normal, and occasionally its congenital 
absence has been noticed. In some cases it is larger, but the 
secreting structure is atrophied, the increase in size being due 
to hyperplasia of fibrous tissue. 

Extirpation of the thyroid gland in animals has produced 
symptoms that are identical with, or that closely resemble, 
myxedema in the human subject. The myxomatous changes 
affect the skin and its appendages ; which are secondary to 
the lesion in the thyroid gland, and probably result from the 
diminished function of this organ, the internal secretion being 
diminished or absent. Sclerotic changes have been observed 
in the blood-vessels and the kidneys. 

Bramwell clearly defines the physiology of the thyroid body 
as follows: "That the thyroid gland is in some manner or 
another (either directly or indirectly) concerned in the regu- 
lation of the metabolism of mucin or of substances which 



MYXEDEMA. 64 1 

form mucin, or that it is concerned in separating from the 
blood some substance or substances which either directly or 
indirectly (possibly through the nervous system) favor the 
production of mucin in the tissues," which, he says, also seems 
proved by the fact that large quantities of mucus are excreted 
by the kidneys as a result of active thyroid treatment in 
cases of myxedema. Extirpation of the thyroid gland in 
animals causes an enormous increase of mucin in the tissues 
in some instances. 

Symptoms. — The onset is slow and the course of the dis- 
ease is chronic. Changes which result from myxomatous 
degeneration of the skin and subcutaneous structures are often 
the first to attract the attention of the patient. The face 
becomes full, coarser, and round (moon-shaped), and the 
countenance is dull. The tissues around the orbit are swollen, 
and may suggest Bright' s disease, but it will be noticed that 
the upper lid suffers as much as the lower. The lips present 
a bluish or purplish color. The nose becomes broader, the 
lips thicker, and the cheeks puffy. The ears are often swollen, 
the tongue is thickened, and the hair is scanty. Baldness not 
infrequently results. The skin sometimes shows a yellowish 
discoloration, being most marked about the exposed parts, and 
is quite resistant upon palpation. It is usually dry and brittle ; 
the secretion of sweat is diminished and the color of the hair 
is changed. The teeth and nails are frequently diseased ; the 
former being carious and the latter brittle. The body and 
neck increase in bulk, as do also the extremities, especially 
the hands and feet. Occasionally there is an increase in the 
saliva. Mental impairment develops as the disease progresses, 
as does also loss of physical activity. The gait becomes 
changed, being clumsy and sluggish. Articulation is im- 
paired, speech being slow. Mental disturbance in some cases 
is pronounced, the patient developing either melancholia or 
mania. The tactile sense, as well as other special senses, — 
sight, hearing, taste, and smell, — is occasionally impaired. 

The temperature is frequently subnormal and the patient 
experiences a sensation of cold. Secondary anemia results ; 
this, however, not being marked. 

The heart's action is slow and feeble. The urine may show 
an increase of mucin when thyroid treatment is instituted. 



41 



642 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



SPORADIC CRETINISM. 

This condition occurs in the young between the ages of two 
and four years, the symptoms resembling closely those of 
adult myxedema. They are frequently ushered in by some 
one of the infectious diseases, notably scarlet fever or measles. 
Fully developed cases of sporadic cretinism are typical in their 
appearance. The body is dwarf-like ; although young in 
years, the patients affected with this disease appear quite old. 
The mental, physical, and sexual developments are much 
interfered with. The features are heavy, the face is broad and 
coarse-looking, the body is thick-set, the abdomen is fre- 
quently pendulous, the hands and feet are swollen, the hair is 
usually abundant, but is straight and coarse, and the skin is 
dry, rough, and often scaly. 

The thyroid gland shows the changes met with in adult 
myxedema, and in some cases is absent. The sexual organs 
are frequently underdeveloped. 

OPERATIVE MYXEDEMA. 

This results from the removal of part, or more commonly 
the whole, of the thyroid gland. The symptoms are similar 
to those already set forth in adult myxedema, and arise 
gradually. 

Diagnosis. — The disease can rarely be mistaken for any 
other condition. The physical and mental changes are pecu- 
liar and highly characteristic. 

Prognosis. — The prognosis is favorable if thyroid treatment 
is instituted early, being especially so in operative myxedema. 

Treatment. — Thyroid extract should be administered as 
early as possible, and should be continued until all the 
symptoms disappear, and then a prophylactic dose must 
be given regularly. The dose varies from ^ of a grain to 
4 grains once daily. It should be increased gradually ; 
large doses frequently produce acute thyroidism, serious 
cardiac depression attending this condition. After the admin- 
istration of this drug loss of weight soon occurs. The mental 
and physical condition begins to improve ; the hair, which is 
frequently thin, becomes thick, and changes to its original 
color. The sweat-glands become active and the heart's action 
is improved. General tonics, such as iron, quinin, and strych- 
nin, may prove of value. 



EXOPHTHALMIC GOITER. 643 



EXOPHTHALMIC GOITER. 

Definition. — A disease characterized by protrusion of the 
eyeballs, enlargement of the thyroid gland, tachycardia, and 
a tremor. 

Synonyms. — Basedow's disease ; Grave's disease ; Parry's 
disease. 

Etiology. — The disease affects all classes of society ; it is, 
however, most frequent between the ages of fifteen and forty, 
being quite rare at the extremes of age. It is commoner in 
the female in the proportion of ten to one. It sometimes fol- 
lows some of the infectious, and occasionally some of the 
nervous, diseases. Not infrequently it exists in several mem- 
bers of the same family. Hereditary tendency is a feature. 
The exciting cause is said to be some profound shock, mental 
disturbances, overfatigue, fright, or great physical effort. 

Pathology. — The protrusion of the eyeball is never so 
marked after death as it is antemortem. It is due to an 
excess of retro-orbital fat and to increased vascularity. The 
thyroid commonly shows a uniform enlargement ; it is firm 
and of a brownish-red color. The chief feature is the increase 
in the secreting structure and marked vascularity. The thymus 
gland may be large. The heart shows hypertrophy and dila- 
tation, or it may be normal. No characteristic lesions are 
found in the nervous system. 

Symptoms. — The symptoms of the disease are probably 
due to some derangement of the nervous system as well as to 
perverted or excessive secretion of the thyroid gland. As stated 
in the etiology, it frequently follows grief, fright, shock, etc. 

The early symptoms are irritability of temper, exophthal- 
mos, and palpitation of the heart. The thyroid enlargement 
is not always noticed from the onset. 

The protrusion of the eyeball often progresses with the 
thyroid enlargement. The eyes appear as though they bulged 
out of the head. Friends sometimes first inform the patient 
of this change. The protrusion may be so great as to render 
proper closure of the eyes during sleep impossible. Rarely 
only one eye protrudes (this commonly being accompanied by 
unilateral thyroid enlargement), or the protrusion of both may 
be very slight. 

Von Graefe's Sign. — Upon lowering the visual plane, 
which may be accomplished by holding an object before 



644 DISEASES OF THE BLOOD AND DUCTLESS GLANDS 

the patient and gradually lowering it, the upper lid fails to 
follow properly the eyeball downward — it lags behind. 

Dalrymple's sign consists in a widening of the palpebral 
fissure, which appears to be due to spasmodic contraction of 
Muller's muscle. 

Stellwag's Sign. — There is infrequent reflex winking, which 
may be ascribed either to the contraction of Muller's muscle 
or to some degree of anesthesia of the cornea. Dalrymple's 
sign is sometimes erroneously credited to Stellwag. Both 
v. Graefe's and Stellwag's signs have been noticed in other 
conditions. 

Mbbius' Sign. — This consists in the failure of convergence 
for near objects. This sign is not always present. 

Vision, as a rule, is not affected. Painful spasm of the 
orbicularis palpebrarum and ulceration of the cornea are rare. 
Watering of the eyes is common. 

The absence of constant dilatation of the pupil rather counts 
against involvement of the cervical sympathetic nerves. 

The enlargement of the thyroid gland is not so extensive as 
is common in cystic goiter. It may be symmetric or asym- 
metric, and an accessory thyroid may be found, which is often 
enlarged. The gland presents pulsation, and on palpation a 
distinct thrill is felt. Upon auscultation usually a loud systolic 
murmur is noticed ; sometimes even a double murmur. The 
protrusion of the eyes and the enlargement of the thyroid 
gland often develop simultaneously. 

The heart action is rapid, varying from 90 to 160 a minute. 
The palpitation may be painful ; the carotids pulsate visibly. 

A muscular tremor affecting the whole body is found in 
nearly all cases. This tremor varies from eight to nine a 
second ; it is usually bilateral, but in rare cases it may be 
unilateral, or may affect a single member. 

Diarrhea and vomiting occur as prominent symptoms in 
many instances. Anemia and loss of weight usually develop. 

Excessive sweating, sensations of heat and elevation of 
temperature, and marked flushings of the face, feet, hands, and 
body generally accompany the disease. 

The urine is usually greatly increased in amount, and may 
contain albumin, and sometimes sugar. The respirations are 
accelerated ; there maybe a nervous cough. Neuralgia, head- 
ache, and mental alteration are not infrequent. Sleep is inter- 
fered with, the patient being restless ; emaciation is marked, 
but the general health is not greatly impaired. The appetite 



ACROMEGALY. 645 

is good, sometimes excessive, and thirst is usually a marked 
symptom. The disease usually runs a chronic course ; re- 
lapses are common. 

Diagnosis. — The diagnosis depends upon the exophthalmos, 
the enlargement of the thyroid gland, tachycardia, and the 
tremor. It is attended with little difficulty. 

Prognosis. — The disease may last for years, there is much 
uncertainty as to recovery, and, as before stated, relapses are 
common. 

Treatment. — The ordinary house diet, well regulated, 
should be given. Hydrotherapy is often valuable. Rest in 
bed and ice-bags applied to the precordium give much relief 
to the patient ; and as a result of this treatment the pulse-rate 
becomes slower and the patient receives much comfort. Digi- 
talis, aconite, veratrum viride, tincture of strophanthus, and 
potassium bromid have been employed in this disease. Opium 
frequently gives great relief. Removal of the thyroid has been 
practised with but little benefit. 



ACROMEGALY, 

Definition. — A disease characterized by enlargement of 
the osseous structures, particularly the bones of the hands and 
feet, with constitutional symptoms. 

Synonyms. — Pachyacria ; megalacria ; Marie's disease. 

Etiology. — The disease is found in all races, commonly 
between the ages of fifteen and forty. The sexes suffer 
equally. Heredity seems to play a slight part in the predis- 
position, and cases are on record where several members of 
a family have been affected. 

Pathology. — The pathology chiefly relates to the osseous 
system and to the pituitary body. The bones of the face 
become altered ; the inferior maxilla is thickened and elon- 
gated, the cheek-bones are prominent, the nasal bones are 
thickened, the supraorbital regions are enlarged and prom- 
inent, and the head in general has a peculiar ape-like appear- 
ance. The anteroposterior diameter of the chest is increased, 
so that the thorax assumes a globular shape, the clavicle, 
ribs, and sternum are enlarged, the shoulders are rounded, 
and curvature of the spine develops (kyphosis and scoliosis). 
From this deformity an ape-like appearance is assumed. The 
vertebrae are thickened and the spinal processes are enlarged. 
The bones of the pelvis are also enlarged and thickened. 



646 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

The long bones most commonly escape, the smaller bones 
being affected. The joints may be enlarged. The bones 
of the feet and hands are elongated and thickened, so that the 
breadth and length are increased. The wrists and the ankles 
may also be increased in size. 

The pituitary body is found either enlarged, the seat of a 
new growth, or atrophied. It is believed that the disease of 
the pituitary body acts as the primary, the fundamental 
lesion, and produces either an arrested, an increased, or a 
perverted secretion ; and this, in return, disturbed metab- 
olism of the body. The thyroid gland is often found en- 
larged. In the progress of the disease the mammary glands, 
the ovaries, and the testicles are sometimes found atrophied 
(these glandular structures seem to bear a relationship to one 
another). 

Symptoms. — The important symptoms of the affection are 
the enlargement of the hands and feet — those relating to the 
osseous system, already noted in the pathology. The skin is 
thickened and warty. The growth of the hair is often increased, 
becoming long and coarse. Headache is common and is usu- 
ally referred to the eyeballs. There is often lassitude. Speech 
is thick and slow. The tongue is flabby and large. Blindness 
may occur from atrophy of the optic disc. Loss of smell and 
of taste are common, and hearing may be impaired. The 
menopause occurs before the normal period. Muscular weak- 
ness and excessive perspiration are common. 

Prognosis. — The prognosis is unfavorable. 

Treatment. — There is no remedy that is known to be of 
service in this disease. The drugs that have been used are 
iodid of potassium and thyroid extract. 



PART VIH 

DISEASES OF THE NERVOUS SYSTEM. 



DISEASES OF THE NERVES. 
NEURITIS. 

Definition. — Neuritis is an inflammation of a nerve ; it 
may be either localized (that is, confined to a single nerve- 
trunk) or multiple (affecting a number of nerves). 

LOCALIZED NEURITIS. 

Etiology. — Cold is most frequently the cause. The affec- 
tion is sometimes due to trauma, such as contusions, stabs, or 
cuts, or to stretching or tearing of a nerve, as might result 
from a fracture or dislocation. Pressure from muscular con- 
traction may also cause this affection. It may result from 
extension, as from disease of the bone through which the nerve 
passes. It is often due to toxins and morbid states arising 
in the course of infectious and constitutional diseases. The 
mineral poisons are not infrequent causes. Alcohol most com- 
monly produces peripheral neuritis. 

Pathology. — The inflammation may be confined to the 
nerve sheath (perineurium), to the interstitial part, or to the 
axis-cylinder. In the first instance the nerve is particularly 
swollen, red, and infiltrated with numerous leukocytes ; in the 
last instance degenerative changes of the axis-cylinder are 
noticed (parenchymatous neuritis). The nuclei of the nerve- 
cells may consist of oily looking globules. The degeneration, 
according to Waller, extends down the nerve, because the 
fibers are cut off from the trophic cells. The muscles may 
undergo atrophy. Increased fibrous tissue may form in the 
nerve if recovery takes place. 

647 



648 DISEASES OF THE NERVOUS SYSTEM. 

Symptoms. — The constitutional disturbance is slight, and 
fever is rarely a symptom. Pain and tenderness are the prin- 
cipal symptoms, and are usually localized to the nerve-trunk 
and its distribution. The pain varies in intensity and character, 
and is described as burning, aching, boring, or shooting. 
Commonly it is aggravated at night, or in positions in which 
pressure upon the nerve-trunk may occur. The nerve -trunk- 
may be swollen, and some reddening of the skin occasionally 
appears. Muscular twitching and contraction sometimes occur 
along the course of the nerve. If the disease be protracted, 
such changes as muscular weakness and wasting, slight edema, 
with a tremor, hyperesthesia, paresthesia, or anesthesia may 
develop. Acute cases usually end in recovery in about two 
weeks. Chronic cases may last for months or years, and may 
then gradually subside. The electric reaction is normal in mild 
cases ; in severe cases the reaction of degeneration may take 
place. 

Diagnosis. — The differential diagnosis between neuritis and 
neuralgia must be made. In neuritis the pain is continuous, 
and occurs along the course of the nerve. In neuralgia the 
pain is intermittent in character, and is often relieved by pres- 
sure, whereas the pain of neuritis is aggravated by pressure. 
Altered sensation is in favor of neuritis. 

Prognosis. — The prognosis is favorable in mild cases. If 
the disease becomes chronic, it may last for months or years. 
Cases due to suppuration are less likely to recover. 

Treatment. — It is important to remove the cause, if pos- 
sible. Rest is essential. When it is possible to splint the 
part, this should be done. Applications of cold by means 
of an ice-bag are useful. In some cases heat is more desirable. 
The use of a blister along the nerve -trunk in severe cases is 
of benefit. If the pain is very severe, morphin hypodermic- 
ally must be resorted to. Salicylate of sodium is of value in 
the forms due to cold and exposure. In the chronic variety 
electricity is of use, galvanism being preferable. The weakest 
current that can be appreciated is most efficient. When wast- 
ing takes place, massage should be tried. 



BRACHIAL NEURITIS. 

Definition. — Inflammation of the brachial plexus. 
Etiology. — This occurs particularly in gouty individuals, 
affecting both sexes equally. The majority of cases arise after 



NEURITIS. 649 

the fiftieth year of life. Exposure to cold is said to be a pre- 
disposing factor. 

Symptoms. — Pain in the course of the distribution of the 
brachial plexus is the prominent feature. It is frequently 
encountered in the wrist, in the axilla, above the clavicle, and 
in the scapular region. At first it is intermittent, and felt only 
upon certain movements. It is usually severe. As in other 
forms of neuritis, trophic changes may occur. The disease is 
not common. 

Prognosis. — The disease lasts for months", sometimes for 
years, recovery rarely being complete. Relapses are extremely 
common. 

Treatment. — The treatment is the same as in other forms 
of neuritis. 

SCIATICA. 

Definition. — Inflammation of the sciatic nerve. 

Etiology. — The disease is more frequent in males than in 
females, in about the proportion of four to one. It is rare in 
children, and is most frequent between the ages of twenty and 
fifty. The gouty and rheumatic diatheses are predisposing 
causes. The exciting cause most often is exposure to cold ; 
wet cold, it is said, being an especially favorable cause. Occa- 
sionally sciatica, it has been claimed, may be due to the poison 
of acute rheumatic fever. Pressure and intrapelvic disease 
may give rise to the affection. 

Pathology. — The pathology is the same as that of other 
forms of neuritis. 

Symptoms. — Pain along the course of the sciatic nerve, — 
which is commonly felt at the back part of the thigh, in the 
region corresponding to the sciatic notch, — behind the knee, 
and below the head of the fibula, is the most important symp- 
tom. The pain may be diffused and ma}' extend from the 
sciatic notch to the toes. All muscular movements aggravate 
the pain. In long-standing cases trophic changes occur. 

Prognosis. — The disease is liable to be obstinate, usually 
lasting for months. 

Treatment. — Rest by means of splinting the limb is impor- 
tant. Attention should be directed to the cause of the disease. 
If of rheumatic origin, the salicylates are useful. The use of 
mercury has been advised by some authorities, notably 
Gowers. Phenacetin, antipyrin, and other members of the 
coal-tar group are useful ; however, in severe cases morphin 



65O DISEASES OF THE NERVOUS SYSTEM. 

is necessary. Injections of chloroform or sterile water into the 
tissues along the course of the sciatic nerve may give relief 
in severe cases. Surgical interference by nerve-stretching 
should be resorted to only when other methods have failed to 
give relief. 

MULTIPLE NEURITIS, 

Definition. — An inflammation involving many nerves, often 
by a symmetric change. These may be affected simultaneously 
or in rapid succession. 

Synonyms. — Peripheral neuritis ; polyneuritis. 

Etiology.— Multiple neuritis is almost invariably caused by 
some toxic agent, the most frequent, with the exception of 
lead and diphtheria, being alcohol. It occurs most often in 
persons who use strong liquors, but malt liquors also give 
rise to the condition. The disease is said to be more preva- 
lent in females than in males. Scarce and improper food and 
exposure to cold are asserted to be predisposing factors. The 
fumes of some gases, such as carbon monoxid from char- 
coal stoves, and the fumes of anilin and bisulphid of carbon, 
are said to cause multiple neuritis through, inhalation. The 
condition is frequently a sequel of infectious diseases ; how- 
ever, it more frequently follows diphtheria than any of the 
others. It takes place as a sequel in enteric fever, and more 
rarely from measles, pneumonia, influenza, scarlet fever, vari- 
ola, varicella, and erysipelas. It is exceedingly uncommon after 
septic infection and syphilis. Neuritis occasionally occurs in 
the course of tuberculosis, but is very frequent in the course 
of leprosy. Of the metallic poisons, lead is the most frequent 
cause, but arsenic and mercury are also occasional factors. It 
occurs in the cachexias, such as malignant disease and anemia, 
and the affection has been noticed in the puerperal state. It 
is sometimes met with in the aged, arterial sclerosis probably 
being the exciting cause. Perforating ulcer and Raynaud's 
rheumatoid arthritis have been attributed to peripheral neu- 
ritis. 

Pathology. — The pathology of multiple neuritis is practi- 
cally the same as that of neuritis occurring in isolated nerves. 
The secondary changes which occur in the muscles are quite 
pronounced. Changes in the spinal cord, such as meningitis 
or chronic myelitis, may be encountered. Vacuolation of the 
ganglion cells and atrophy of the gray matter sometimes ac- 
company multiple neuritis. 



NEURITIS 65I 

Symptoms. — The symptoms vary. According to Gowers, 
three distinct varieties must be differentiated as to the promi- 
nence of certain symptoms, such as the motor and sensory 
phenomena, or those of incoordination. Pure types of each 
class may exist, but it is much more usual to find them 
combined. The disease mostly begins abruptly, but pro- 
dromes may exist, and may extend from a period of weeks 
to months, characterized by numbness and tingling in the 
hands and feet and by muscular cramps. In the acute cases 
the onset resembles the beginning of the acute infectious dis- 
eases. The temperature rises abruptly to 102 F. or 104 F., 
often with splenic enlargement, slight albuminuria, and even 
jaundice. Active pain in the limbs, with slight swellings at the 
articulations, is sometimes present, so that the attack may re- 
semble acute rheumatic fever. Numbness and tingling, some 
pain, and muscular cramp, which occurs in the extremities, pre- 
cede or accompany loss of power in certain muscle groups. This 
is an early phenomenon. The extensors of the hands and the 
anterior tibial group are the muscles chiefly involved ; wrist- 
and foot-drop, as a result, are quite characteristic. Tenderness 
in the muscles, especially in alcoholic cases, aggravated by 
the least change of posture or by the slightest pressure, is a 
symptom of great importance. Paralysis may develop rapidly, 
and be complete in a few days. Occasionally the onset is 
more gradual, the paralysis requiring several weeks before 
it occurs. Either the arms or the legs may be involved, but 
the paralysis is always symmetric. It is most common for 
both arms and both legs to be affected, the lower extremity 
being more frequently involved than the upper. The muscles 
primarily involved are those at the periphery of the part, as 
below the elbow and knee, principally the groups supplied by 
the musculospiral and popliteal nerves. From a loss of 
power in the muscles of the anterior surface of the leg the 
"steppage" gait, in which the thighs are unduly flexed, re- 
sults. The muscles of the neck, back, chest, and abdomen 
are rarely involved, save in the severest cases. When pa- 
ralysis of the muscles of respiration or of the diaphragm takes 
place, the attack is liable to terminate fatally. Increased 
cardiac action and paralysis of the larynx occur from involve- 
ment of the pneumogastric nerve. Unless the spinal cord is 
affected the sphincters are not involved. Only in neuritis due 
to diphtheria have the cranial nerves been found affected ; 
however, in rare instances there may be paralysis of the 



652 DISEASES OF THE NERVOUS SYSTEM. 

third, fourth, and sixth nerves. Sooner or later nutrition of 
the muscles suffers. They become wasted and flabby, and 
deformities from contractures arise. Sensory involvement has 
already been indicated. It consists in numbness, tingling, 
and a pricking sensation, as of pins and needles, especially 
in the hands and feet. Fibrillary tremor is sometimes pres- 
ent in the affected muscles. Incoordination is not infre- 
quent. There is difficulty in employing the hands for deli- 
cate manipulations, and a decided unsteadiness of gait is 
noticeable. The resemblance to locomotor ataxia is occasion- 
ally marked. The knee-jerks are absent in severe cases. There 
is often slight edema of the ankles and hands. Glossy skin, 
loss of hair, and trophic changes in the nails are not un- 
common. 

Electric Changes. — The degree of irritability of nerve and 
impaired contractility of the muscle are of importance, both 
for diagnosis and prognosis. From secondary changes in 
the muscles it may be necessary to employ a strong galvanic 
current. 

Complications. — Pulmonary complications, especially when 
the respiratory muscles are affected, are frequent, and may be 
the cause of death. Often in the alcoholic variety there is 
pulmonary tuberculosis. 

Prognosis. — The severer cases may prove fatal in one or 
two weeks from paralysis of the respiratory muscles, but this 
is rare. The disease is most often prolonged ; recovery is 
gradual, and may extend over a period of months or years. 
The muscular power returns slowly. Complete recovery, 
however, is the rule, even when marked paralysis has occurred, 
and has been prolonged for more than a year. 

The Alcoholic Variety. — This is more frequent in women, 
in whom it is exceedingly difficult to get a history. The 
premonitory symptoms consist of cramps, numbness, and 
slight incoordination. The paralysis takes place most com- 
monly in the lower extremity, later showing itself in the 
upper extremity. The symptoms are even accompanied 
by severe colic resembling visceral neuralgia. The pulse 
is rapid, weak, and irregular, and vomiting, due to the gastric 
disturbance, is frequent. Mental symptoms such as occur 
in delirium tremens are common. There is loss of memory, 
especially for recent events, the patient becoming suspicious 
of attendants or friends, and showing various delusions. Con- 
vulsions are rare. 



NEURITIS. 653 

Occasionally recurrence takes place, the interval between 
the attacks varying from a few months to several years. 

Treatment. — It is important to ascertain the cause, which 
should be removed if possible. In the case of alcohol, a 
trustworthy nurse should be employed or the patient should 
be treated in the hospital. Absolute rest in bed is important. 
When the pain is severe, splinting, if practicable, should be 
employed. Hot or cold applications, whichever are most 
grateful to the patient, may be used. If the pain is severe, 
morphin may have to be resorted to. Care should be taken 
to prevent contractures, which is best done by the use of 
splints. When cold has been the causative factor, the sali- 
cylates are of value. Iron and cod-liver oil are important as 
tonics. Massage and electricity should be employed in the 
later stages of the disease. A weak galvanic current may 
relieve pain, the positive pole being passed over the painful 
muscles and nerves. 

ENDEMIC NEURITIS, 

Synonyms. — Beriberi ; kakke. 

Etiology. — This disease is prevalent in parts of Japan, in 
the Philippines, in India, and along the coast of Brazil. It 
is believed to be due to a special micro-organism. This 
view, however, is not generally accepted. It is supposed 
that the disease may be acquired by contagion. It has been 
thought that a diet of decayed fish or spoiled vegetables, 
or a diet of certain kinds of mussels, may produce the affec- 
tion. Other observers have asserted that the disease is trans- 
mitted through drinking-water. 

Symptoms. — The disease usually begins with a sense of 
heaviness in the extremities, the muscles tiring easily, per- 
verted sensation, and with great irritability of the heart. There 
is fever, edema, rarely anasarca. The edema shows itself first 
in the legs, and is quite constant. The urine is scanty ; albu- 
min is not often present. An increase in the amount of urine 
shows improvement in the patient's condition. There is an 
early change in the electric reaction, particularly of the peroneal 
nerves, showing a slight reaction of degeneration. 

The mortality varies from 3 % to 60 <f or 70 c / c , as the fatal 
cases are those in which there is involvement of the phrenic 
or pneumogastric nerve. 

Treatment. — The treatment consists primarily in the re- 
moval of any and all causative factors, and then in treating the 



654 DISEASES OF THE NERVOUS SYSTEM. 

disease as in other forms of neuritis. On account of the great 
cardiac asthenia, heart tonics are necessary, as caffein, strych- 
nin, and alcohol. A mild purge at the onset is beneficial. 



DISEASES OF THE CRANIAL NERVES. 

DISEASES OF THE OLFACTORY NERVE. 

Anosmia (loss of smell) is most often due to local trouble 
in the nasal mucosa. If the olfactory bulbs are damaged by 
tumors, syphilitic lesions, or injury, loss of smell may occur. 

Treatment. — The treatment depends upon the cause. 
Strychnin, which experimentally stimulates the olfactory 
nerve, should be tried. 

DISEASES OF THE OPTIC NERVE. 

Etiology. — This disease may occur in the optic nerve, in 
the chiasm, or in the tract. These parts may be damaged by 
tumors, syphilitic lesions, hemorrhage, or meningitis. 

Optic neuritis is usually a symptom of grave disease, result- 
ing especially from cerebral tumors or abscesses. 

Symptoms. — If the neuritis be complete, blindness will 
occur upon the affected side. The pupillary reaction is ab- 
sent, and atrophy can be detected in a few weeks by the 
use of the ophthalmoscope. If the damage be partial, nar- 
rowing of the field of vision occurs. Disease of the optic 
chiasm, when complete, causes blindness of both eyes and 
total loss of the pupil reflexes to light. Lesions in the situa- 
tion of the optic tract, between the optic center and the chiasm, 
are accompanied by heteronymous hemianopia. Only those 
lesions due to syphilis are amenable to treatment. 

OPTIC NEURITIS. 

Etiology. — In rare instances this may be due to exposure 
to cold and wet. The majority of cases, however, are sympto- 
matic of cerebral disease. Gowers and Bramwell claim that 
80^ of the cases are associated with cerebral tumors. It 
occurs in the course of some of the infectious diseases, such as 
enteric fever, scarlet fever, measles, and influenza. It takes 
place in diabetes, leukemia, and Bright's disease. The disease 
may arise in several members of a family, the females most 
often escaping. 



DISEASES OF THE CRANIAL NERVES. 655 

Pathology. — The optic nerve reveals interstitial neuritis. 
The entire nerve or only parts of it may be affected. Swelling 
of the papilla is noticed, with haziness of the margins, the con- 
dition being known as papillitis (choked disc). In some rare 
instances edema is also added, so that the papilla becomes' 
very prominent and assumes the shape of a mushroom. In 
rare instances optic neuritis may exist without the choked 
disc. It maj- be secondary to inflammation of the brain 
membranes. 

Symptoms. — In the severest cases early symptoms may be 
entirely absent, in which case the disease can be recognized only 
by means of the ophthalmoscope. Vision may be but little 
affected ; usually there is some contraction of the visual field. 

Prognosis. — Mild cases may recover, but even these fre- 
quently terminate with some loss of vision. Severe cases 
almost invariably give rise to total blindness. 

Treatment. — The treatment is symptomatic. If there be 
evidences of syphilis, mercury and iodid of potassium are in- 
dicated. Tobacco and alcohol must be prohibited. 

PARALYSIS OF THE OCULAR NERVES. 

The muscles of the eyeball are supplied by the third, fourth, 
and sixth nerves. Affections of these nerves belong to the 
domain of ophthalmology. 

DISEASES OF THE FIFTH NERVE (TRIFACIAL). 

The fifth nerve is the nerve of sensation of the face and the 
anterior part of the scalp. It consists of three main trunks : 
The ophthalmic division supplies the orbit, the lacrimal glands, 
the skin of the forehead and scalp, the tip of the nose, and the 
anterior part of the nasal mucous membrane. The supenor 
maxillary division supplies the skin over the malar bone, the 
root of the nose, the infraorbital region, the upper lip and the 
greater part of the nasal mucous membrane, the palate, the 
upper part of the pharynx, and the teeth in the upper jaw. 
The inferior maxillary division supplies the skin in the temporal 
region, lower lip, chin, parts of the ear, and external auditoiy 
meatus, and also the mucous membrane of the mouth, the 
tongue, and the lower teeth. The motor division of the nerve 
innervates the muscles of mastication. 

Paralysis of the Motor Portion. — Parts of a nerve or the 
entire nerve may be affected. Paralysis is usually due to deep- 



656 DISEASES OF THE NERVOUS SYSTEM. 

seated disease, as the nerve is rarely affected peripherally. It 
may arise from pressure from tumors, meningitis, disease of 
the bone, or syphilis. 

Symptoms. — The important symptoms are severe pain 
along the course of the distribution of the nerve, accompanied 
by anesthesia or hyperesthesia. Paralysis of the muscles of 
the jaw may occur. Atrophy of the muscles of the face may 
result. 

Treatment. — Treatment should consist in the use of iodid 
of potassium in large doses. If the pain be severe, opium in 
some form will have to be resorted to. Galvanism and fara- 
dism are of use in some cases. 

DISEASES OF THE SEVENTH NERVE (FACIAL PARALYSIS; 
BELL'S PALSY). 

Etiology. — From the exposed position of this nerve neuri- 
tis due to cold and exposure frequently takes place. Disease 
of the middle ear may also give rise to injury of the nerve. 
Traumatism is responsible in some instances. It may be due 
to lesions about the facial nucleus. 

Symptoms. — The appearance of the patient is characteristic. 
Expression has changed upon the affected side of the face, 
which is immobile. The furrows upon the face and forehead 
are smoother than upon the unaffected side. The labionasal 
fold has disappeared, the mouth being drawn toward the 
healthy side, with the angle of the mouth depressed. The eye 
is open, owing to paralysis of the orbicularis palpebrarum. 
There is inability to move the lid, also to use the facial mus- 
cles to laugh or smile upon the affected side, the mouth being 
drawn toward the unaffected side. The patient can not wrinkle 
the forehead. The eye remains open during sleep. The patient 
can not whisper, blow out a candle, or expectorate properly, 
and saliva is constantly dribbling from the mouth. Speech may 
be affected. If the nerve be damaged between the geniculate 
ganglion and the region of the chorda tympani, taste is lost 
upon the anterior two-thirds of the tongue. There may be 
abnormal sensitiveness to sound. Spasmodic twitching in the 
paralyzed muscles occurs late, and secondary contracture 
may take place in severe cases. In mild cases electric reac- 
tion shows diminished irritability, or in very mild cases no 
electric changes may be apparent. In severe cases irritability 
is completely lost to both currents. 

Prognosis. — If there be complete reaction of degeneration, 



DISEASES OF THE CRANIAL NERVES. 657 

recovery can not be expected for several months. The ma- 
jority of cases, however, recover completely. ■ 

Treatment.— Cases due to cold and exposure are best 
treated by large doses of the salicylates ; syphilitic cases, by 
the use of iodid of potassium in large doses. Warm fomenta- 
tions are of use in many cases. In the severer cases a blister 
should be applied behind the ear.* In case of severe pain, 
antipyrin and phenacetin are of value. The application of 
weak galvanic currents preserves the nutrition of the muscles 
and hastens recovery. 

DISEASES OF THE AUDITORY NERVE. 

Symptoms of the affection of this nerve consist in impair- 
ment of hearing or complete deafness. Disease in the laby- 
rinth is the most frequent cause. It may be due to acute or 
chronic inflammation, spreading from the tympanum, to 
syphilis, or, in old persons, to degenerative changes. It may 
result from tumors and meningitis. Atrophy may occur in 
tabes, and may appear in elderly persons. 

DISEASES OF THE GLOSSOPHARYNGEAL NERVE. 

Very little is known of diseases of this nerve, owing to its 
numerous connections and absence of isolated lesions. It is 
most likely that paralysis of the nerve gives rise to difficulty 
in swallowing, and to loss of sensation in the roof and walls of 
the pharynx. It has as yet not been determined whether the 
glossopharyngeal nerve is a special nerve of sense or not. 

DISEASES OF THE PNEUMOGASTRIC OR VAGUS NERVE. 

This nerve has a long, course, being distributed to the 
pharynx, esophagus, larynx, lungs, heart, stomach, spleen, 
and intestines. Paralysis may occur from disturbance within 
the skull, such as injury, and from pressure by morbid growths, 
meningitis, or aneurysm. The nucleus of the nerve may suffer 
from inflammatory changes. Causes outside of the skull may 
be due to surgical operations in dividing the nerve or to com- 
pression by tumors. 

Symptoms. — Division of the nerve in animals is followed 

by an increase of cardiac action, while the respiration becomes 

slower and more pronounced. The same symptoms occur 

when the nerve is divided in man from surgical operations or 

42 



658 DISEASES OF THE NERVOUS SYSTEM. 

from injuries. Paralysis of the vocal cords is likely to occur. 
There is difficulty in swallowing and vomiting is frequent. 
Treatment. — The treatment is symptomatic. 

DISEASES OF THE SPINAL ACCESSORY NERVE. 

Diseases similar to those which give rise to disease of the 
pneumogastric also affect the spinal accessory. When the 
external part of the nerve is diseased, paralysis of the sterno- 
cleidomastoid and upper part of the trapezius occurs. This is 
followed by wasting. 

Treatment. — The treatment is symptomatic. 

DISEASES OF THE HYPOGLOSSAL NERVE. 

This is purely a motor nerve, supplying the muscles of the 
tongue. Paralysis occurs from cerebral lesions involving the 
fibers of the nerve from the cortex to its nucleus. Lesions 
of the nucleus are most often bilateral. Locomotor ataxia 
and syringomyelia give rise to unilateral disease. Peripheral 
paralysis is extremely uncommon. 



NEURALGIA, 

Definitions. — Neuralgia is a term used to denote pain in 
the course of a nerve, unattended by structural change. The 
border-line between neuritis and neuralgia can not be too 
closely drawn, but the term neuralgia should be used to ex- 
press pain unattended by motor or trophic changes. 

Etiology. — Neuralgia is particularly a disease of middle 
life. It is rare in childhood and in old age, and occurs more 
frequently in men than in women. Some females show a 
hereditary tendency to neuralgia, and it is frequent in neurotic 
females. It is common in debilitated and anemic individuals, 
frequently accompanying overwork and worry. The disease 
is often unilateral, and when so, the left side is more frequently 
affected than the right. Cold is a common exciting cause, as 
are malaria and gout. Irritations of various kinds, such as a 
carious tooth, may produce neuralgia. Eye-strain is a pre- 
disposing cause. 

Symptoms. — Pain is the most important symptom. It 
shows a marked tendency to periodicity, and is paroxysmal in 
nature, being described as burning, shooting, or darting in 
character, not increased by motion, and often relieved by 



NEURALGIA. 659 

slight pressure or friction. There may be increased secretion 
of saliva and tears, and a slight elevation of temperature. 
Muscular twitchings may occur. The duration of an attack 
varies from an hour to a day or more. Neuralgias show a 
constant tendency to recur at irregular intervals. 

Neuralgia is very common along the course of the fifth 
nerve, when it has been called tic douloureux. It may involve 
the branches of the fifth nerve, and when it involves the 
ophthalmic branch, a tender point at the extremity of the 
nerve — the supraorbital notch — is indicated by the patient. 
When it involves the second branch, the infraorbital region is 
painful, and in the inferior maxillary division the tender point 
is in the region of the zygomatic arch. 

Other forms of neuralgia are known as cervico- occipital, 
brachial, neuralgia of the phrenic nerve (which is exceedingly 
rare), intercostal neuralgia, lumbo-abdominal neuralgia, visceral 
neuralgia, sacral neuralgia, coccygodynia, and neuralgia of the 
feet. By the term reflex neuralgia is meant pain due to dis- 
ease in organs distant from the actual seat of pain. This may 
occur in diseases of the eye, ear, nose, and throat, in diseases 
of the stomach and liver, or in uterine disease. 

Prognosis. — The prognosis as regards recovery is good, 
although the disease is extremely stubborn, and shows a con- 
stant tendency to recur. 

Treatment. — It is especially important to treat the under- 
lying condition : thus, if the disease be reflex, it is important 
to give attention to the affection giving rise to it ; if it be ane- 
mia or malaria, these causes must be given full attention. 
Hygienic treatment is of importance. Change of scene and 
residence, with good nourishing diet, are necessary. Many 
drugs have been recommended for the treatment of the par- 
oxysm — quinin, the coal-tar analgesics (such as phenacetin), 
antifebrin, and so on. A combination of phenacetin and 
caffein, or a combination of phenacetin and salicylate of 
sodium, may be of use. Morphin should be avoided if possi- 
ble, as there is great danger of the patient acquiring the opium 
habit. Aconitin, gelsemium, and belladonna are valuable. 
Local treatment is sometimes of use ; thus, hot and cold 
applications, liniments containing menthol, and occasionally 
electricity may be tried. In protracted cases surgical interfer- 
ence should be thought of. Often surgery has rendered bril- 
liant results. 



660 DISEASES OF THE NERVOUS SYSTEM. 



DISEASES OF THE SPINAL CORD. 

ACUTE SPINAL MENINGITIS. 

Definition. — -This term includes the various acute inflamma- 
tions which affect the spinal pia mater or dura mater. If the 
inflammatory condition involve chiefly the pia mater, the 
process is diffuse, and extends often to the internal surface of 
the dura mater. A separate affection of the dura, as in acute 
purulent inflammation, occurs only secondary to disease of the 
bone or from trauma. 

Synonyms. — Acute spinal leptomeningitis ; acute internal 
meningitis. 

Etiology. — The disease is always due to infection from 
micro-organisms, and most frequently the micro-organisms are 
of the pyogenic group. In tuberculosis in which disease of 
the cerebral membranes also occurs the spinal membranes are 
likely to be affected. Cerebrospinal fever, an affection of the 
membrane of the cord, is almost constantly associated with 
inflammation of the membranes of the brain. The affection 
arises in the course of the acute infectious fevers, such as 
croupous pneumonia, scarlet fever, enteric fever, and small- 
pox, and in the course of pyemia and septicemia. The dis- 
ease may result from direct or indirect injury to the spinal 
column, from fractures or wounds, or from operation on the 
vertebral column. This affords a ready access to bacteria 
causing infection. Acquired syphilis of recent origin may give 
rise to an acute inflammation of the membranes of the cord, 
but this is rare, the process being much more likely to be sub- 
acute — that is, nonsuppurative. The affection appears more 
commonly in men than in women, and is more frequent before 
early adult life than after this period. Exposure to cold. and 
wet, traumatism, and overexertion may be said to be predis- 
posing causes. 

Pathology. — In the first stage of the disease the internal 
membranes are hyperemic ; later, an exudate forms, which may 
be fibrinous, semisolid, fluid, pus-like, or purulent. Microscopic- 
ally, numerous leukocytes, a few red blood-cells, and fibrin 
are noted in the -exudate. The inflammatory process may 
spread to the nerve-roots. When the pathologic process is 
of a tubercular nature, a gelatinous exudate is encountered, and 



ACUTE SPINAL MENINGITIS. 66 1 

tubercles are noticed. The cord may be invaded by the pus, 
producing myelitis. 

Symptoms. — As the lesions are rarely entirely spinal, and 
as parts of the cerebral meninges are also involved, the purely 
spinal symptoms are likely to be masked by the cerebral 
symptoms. It is, therefore, rare that the symptoms should 
alone be associated with cord phenomena. The disease 
usually begins with well-marked chills and a temperature 
which is of the septic type. There is severe pain in the back, 
increased by motion, which radiates into the upper and lower 
extremities. Rigidity of the muscles of the back, and some- 
times opisthotonos, occurs. Tonic spasm in the muscles of 
the extremities and of the abdomen and chest is prominent. 
Occasionally tonic spasm gives place to clonic spasm. Hyper- 
esthesia is general and marked, the reflexes are exaggerated, 
and ankle-clonus is pronounced. There may be retention 
of urine and feces from paralysis of the sphincters. Kernig's 
sign may be present. (See page 251.) If the acute symptoms 
subside, paralyses show themselves, paraplegia being the most 
common form. The reflexes become normal, and finally dis- 
appear, so that loss of knee-jerks occurs late in the disease. 
In severe cases death may take place in a few days. In the 
majority of instances the duration is from one to two weeks. 
Even in cases in which recovery occurs, rigidity and weakness 
of the muscles may last for months or years. 

Diagnosis. — The direct diagnosis depends upon the severe 
pain in the back, radiating to the upper and lower extremities, 
and upon the rigidity of the muscles, the hyperesthesia, and 
the acute febrile course, with septic phenomena. 

Prognosis. — Danger to life is imminent, and it is usually 
proportionate to the severity of the symptoms and the gravity 
of the fever. Traumatic cases are most liable to recover, 
especially when the affection occurs in persons in middle life ; 
however, the prognosis must be put down as exceedingly 
serious. 

Treatment. — Absolute rest in bed is important. If the 
patient can be induced to lie upon his side, it is better than to 
have him rest upon the back. Mild laxatives are useful. 
Severe pain should be counteracted by the use of opiates. 
Dry or wet cups along the spine are useful, followed by the 
application of ice-bags. Gowers favors mercurial inunctions. 
For the contractures and pain which arise during the course 
of the disease, hot baths and hot douches are of use. If there 



662 DISEASES OF THE NERVOUS SYSTEM. 

should be bone disease with pus formation, surgical interfer- 
ence is necessary. 



CHRONIC SPINAL MENINGITIS, 

Definition. — A chronic inflammatory affection of the in- 
ternal surface of the dura mater or of the pia and arachnoid 
of the spinal cord. 

Synonyms. — Chronic leptomeningitis ; chronic internal 
pachymeningitis. 

Etiology. — Chronic spinal meningitis is frequently due to 
syphilis. The form due to disease of adjacent bone, which is 
usually of tubercular nature, is the variety that will be de- 
scribed here. It may occasionally be primary, although this 
is rare, when exertion and exposure to cold are said to favor 
its development. It may result from severe concussion of the 
spine. It most commonly follows disease of the bone, such as 
caries, sarcoma, or carcinoma affecting the vertebral column. 
It may also follow the acute variety. 

Pathology. — The process may be localized or quite general. 
In mild cases the internal membranes are simply opaque and 
somewhat granular. In advanced cases the membranes are 
thickened, owing to formation of fibrous connective tissue, and 
the blood-vessels of the pia also show fibroid thickening of their 
coats. The nerve-cells at the periphery of the cord frequently 
undergo degenerative changes and become atrophied. The 
nerve-roots may also be thickened and compressed. Hemor- 
rhages may occur in the membranes. Degenerative changes, 
both ascending and descending, are frequently observed. The 
cerebrospinal fluid may be increased in density. 

Symptoms. — The symptoms vary, depending upon the 
amount of the spinal membrane involved. They usually con- 
sist in pain in the back, increased by movement ; stiffness of 
the muscles ; and, if the cervical region be involved, retrac- 
tion of the head. Pain upon pressure over the vertebral 
column, which may radiate to the upper or lower extremi- 
ties, is a symptom. Slight tremor, and occasionally clonic 
spasm in one or more extremities, combined with areas of 
hyperesthesia, are noticed. After a longer or shorter interval-, 
of weeks or months, paralytic phenomena appear, with loss 
of sensation, the muscles being wasted, and reactions of degen- 
eration manifest themselves. 



HYPERTROPHIC CERVICAL PACHYMENINGITIS. 663 

Diagnosis. — The diagnosis depends upon the gradual on- 
come of the symptoms just enumerated, without fever. 

Prognosis. — The prognosis varies. Danger to life arises 
from the impaired health due to prolonged disability. In 
some cases, through treatment, the irritative symptoms dis- 
appear, and partial return to health occurs. The prognosis is 
most favorable in traumatic cases in which the lesion is small 
in extent, and in which there is the possibility of surgical 
interference. 

Treatment. — Rest in bed is of the greatest importance. 
Counterirritation by a mild application of the Paquelin cautery 
is of use. It relieves pain and aids absorption of certain in- 
flammatory products. Hot baths and hot douches to the 
spine are of great benefit in relieving pain. Iodid of potassium 
and mercurial inunctions must be tried in syphilitic cases. 
Opiates should be resorted to only when the pain can be 
relieved in no other way. Massage and galvanism are of 
value when muscle wasting begins. The general hygiene of 
the patient must be looked after. 

HYPERTROPHIC CERVICAL PACHYMENINGITIS. 

Definition. — A chronic inflammation of the dura mater, 
affecting particularly the inner layer, involving also parts of 
the pia and arachnoid, which may lead to decided thickening 
of the dura mater of the cord, producing irritation and com- 
pression of the nerve-roots and of the substance of the cord 
in the cervical region. 

Etiology. — The disease occurs more frequently in men 
than in women, between the ages of forty and fifty. The 
majority of cases are not of syphilitic origin. Local trauma 
and exposure to cold may be said to predispose. It is a very 
rare affection. 

Pathology. — In this disease the dura mater becomes 
greatly thickened, owing to the hyperplasia of the fibrous 
connective -tissue. In some portions fully developed fibrous 
connective tissue is observed. The arteries may reveal thick- 
ening of the coats, or there may be hyaline degeneration. 
The dura may become closely adherent to the pia and arach- 
noid. 

Symptoms. — The early symptoms consist of pain between 
the shoulders, in the back of the neck, and in the head, with 
slight rigidity of the muscles, tenderness over the cervical 



664 DISEASES OF THE NERVOUS SYSTEM. 

vertebrae upon pressure, anesthesia and paresthesia in this 
region, and symmetric pain in the region of distribution of the 
ulnar and median nerves. These symptoms are due to irrita- 
tion of the nerve-roots. The rigidity of the muscles may be 
accompanied by a coarse tremor. After a variable period, of 
weeks or months, the pains disappear, giving place to 
paralytic phenomena, due to compression of the nerve- 
roots. Partial or complete anesthesia takes place. Muscu- 
lar atrophy in the region of the median and ulnar nerves, 
and reactions of degeneration, are prominent. The paralysis 
and wasting occur in the muscles of the hands, and contrac- 
tions in the flexors of the fingers may lead to a peculiar 
deformity of the hand. Later, the disease may extend to 
other portions of the cord, and sensory symptoms below 
the lesions may arise. Occasionally the sphincters are af- 
fected. Peculiar speech may develop, known as the " staccato 
speech," resembling the form observed in multiple sclerosis. 
It is said to be due to embarrassed respiration. The pupillary 
reaction is sluggish. It is important to remember that the in- 
volvement of muscles is symmetric. 

Diagnosis. — In typical cases the diagnosis is easy. Tumors 
of the cord may give rise to difficulty in diagnosis, but symp- 
toms from pressure of tumors of the cord come on much more 
rapidly than in pachymeningitis. The disease should be diag- 
nosticated only in the absence of disease of the bones of the 
vertebral column. 

Prognosis. — The progress of the disease may extend over 
many years. In rare cases recovery is said to have occurred. 

Treatment. — Attention should be given to the general 
hygiene of the patient and good nutrition should be main- 
tained. Pain should be relieved. Warm baths are useful, 
and it has been said that the galvanic current gives relief. 

HEMORRHAGE INTO THE SPINAL MEMBRANES. 

Definition. — Hemorrhage within the dural sac, known as 
intrameningeal, or hemorrhage external to the dura, known 
as extrameningeal. The latter form is by far the more common. 

Synonym. — Meningeal spinal apoplexy. 

Etiology. — It is most often the result of injury, as from- 
blows or falls. Some diseases accompanied by convulsions may 
lead to spinal hemorrhage from interference with the circula- 
tion of blood in the spinal canal. It may appear in the blood 



HEMORRHAGE INTO THE SPINAL MEMBRANES. 665 

dyscrasias and in the acute infectious diseases ; also as a result 
of rupture of an aneurysm into the spinal canal, in which the 
vertebrae have been eroded. It may occur from the extravasa- 
tion of blood from a cerebral hemorrhage into the membranes 
of the cord. It may sometimes arise without discernible cause. 
It is more prevalent in males than in females, occurring at any 
period of life. It is exceedingly rare as compared with hem- 
orrhage into the cerebral meninges. 

Pathology. — Hemorrhage into the spinal membranes is 
most frequently located in the cervical region. It is rarely 
very extensive, and compression of the cord is not pronounced. 
It may occur between the pia and the dura, or it may be sub- 
dural or subarachnoid. Subarachnoid hemorrhage often causes 
compression of the cord. Hemorrhages into the canal of the 
cord are very rarely noticed. 

Symptoms. — Slight hemorrhages may take place without 
giving rise to symptoms, the onset, as a rule, being rather 
acute. Severe and sudden pain in the back, usually corre- 
sponding to the point at which the hemorrhage occurs, is the 
earliest symptom. This is accompanied by hyperesthesia and 
tingling in the extremities, particularly the arms. Muscular 
spasm is noticed early. Opisthotonos is not rare. There may 
even be general convulsive movements, due to irritation of the 
anterior nerve-roots. If the effusion of blood be sufficiently 
profuse to cause pressure upon the cord, anesthesia and para- 
plegia may result, the paralysis rarely being absolute. If the 
lesion occur at any place other than in the vicinity of the 
lumbar region, the knee-jerks are retained. Early in the 
course of the disease there may be retention of urine. Con- 
sciousness may be impaired early in the attack, but in the 
majority of cases the mind is unaffected. 

Diagnosis. — The diagnosis depends upon the combination 
of pain with symptoms of nerve-root irritation without fever. 

Prognosis. — Early in the course of the hemorrhage danger 
is most imminent in severe cases. It is graver in those cases 
which involve the cervical region, in which respiratory embar- 
rassment is likely to arise. Quite a large number of cases re- 
cover. Paralytic and spastic symptoms may last for months, 
and even then may completely disappear. 

Treatment. — Absolute rest is necessary, the patient lying 
upon the face or upon the side. Local abstraction of blood 
by cupping or scarification over the spine in the region of the 
pain has been advised, and ice-bags to the spine and morphin 



666 DISEASES OF THE NERVOUS SYSTEM. 

hypodermically are useful. Violent purging should be avoided. 
If life is threatened, surgical interference should be tried. In 
intradural hemorrhages the membrane may be opened with 
success in some cases. 

ANEMIA AND HYPEREMIA OF THE SPINAL 

CORD. 

It is impossible to give a clear clinical description of anemia 
and hyperemia of the spinal cord. It has been experimentally 
proven that anemia of an area of the spinal cord abolishes 
functions, and, if long continued, may lead to necrosis of the 
nerve tissues ; but this can result only from structural changes 
in blood-vessels. Mechanical congestion due to influence of 
gravitation may occur in weakened individuals and give rise to 
an aching sensation in the spine and legs when the body is in 
the recumbent posture. The vessels of the cord become 
dilated if there be prolonged or violent activity of the nerve 
elements, such as may take place in epilepsy, hydrophobia, or 
strychnin -poisoning, or after violent exercise. 

PARALYSIS FROM LESSENED ATMOSPHERIC 
PRESSURE. 

Definition. — A nervous disease characterized by paraplegia 
and nervous symptoms following exposure to increased atmos- 
pheric pressure. 

Synonyms. — Caisson disease ; divers' paralysis. 

Etiology. — The production of this disease requires an in- 
crease of pressure of more than two atmospheres. The disease 
is due to the sudden reduction of atmospheric pressure which 
occurs on returning from a caisson to the outer air. If the 
lowering of pressure be very gradual, the symptoms rarely, if 
ever, arise. Alcoholism, chronic nephritis, myocarditis, and 
obesity are all predisposing factors. Novices are more likely 
to be affected than those who have been accustomed to work 
at gradually increasing depths. It is supposed that the risk 
of contracting the disease is increased when a person with an 
empty stomach enters a caisson. 

Pathology. — It has been suggested that this disease is due to 
the liberation of gas (nitrogen) from the blood. Myelitis, hem- 
orrhages, and congestion have been noticed at autopsies. The 
cause of the disease must still be regarded as being very obscure. 



HEMORRHAGE INTO THE SPINAL CORD. 66j 

Symptoms. — The symptoms come on abruptly after a sus- 
ceptible person leaves a caisson and returns to the surface. 
Occasionally the onset may be delayed for half an hour. 
Sometimes the symptoms consist of nausea, vomiting, tin- 
nitus aurium, and severe pains in the joints. Collapse may 
come on rapidly, and death may result in a few hours. In 
milder cases the principal symptoms consist in tingling and 
pain in the extremities, which gradually disappear in a day or 
two. Under such circumstances no paralysis occurs. In the 
severer cases paralysis always takes place. It is rarely hemi- 
plegic, mostly showing itself as a paraplegia. If the paralysis 
is complete, it may last for weeks, and then become permanent ; 
if it is partial, recovery ma}' occur in a few days. Anesthesia 
and implication of the sphincters take place in severe cases. 
Occasionally petechiae have been observed. 

Prognosis. — Less than 10^ of the cases prove fatal. If 
death occurs, it takes place earl}-. The cases that show 
cyanosis are serious even if no paralysis occurs. 

Treatment. — The prophylaxis consists in compelling divers 
gradually to accustom themselves to increased pressure, lim- 
iting the exposure to a short time at first and increasing it by 
degrees. The diver should take food before entering the caisson. 

For the attack, morphin cautiously given to relieve pain is 
valuable. Bandaging the limbs tightly has been recom- 
mended. The fluid extract of ergot in large doses is said to 
control the irritative symptoms. 

HEMORRHAGE INTO THE SPINAL CORD* 

Definition. — This term means that the hemorrhage does 
not occur between the membranes of the cord, but directly 
into its substance. It is a primary condition. 

Synonym. — -Spinal apoplexy. 

Etiology. — Ninety per cent, of the cases are due to trauma, 
such as a fall upon the back, a blow, fractures and dislocations 
of the vertebrae, and violent muscular exertion. It may occur 
in the blood dyscrasias, especially in hemophilia. It may 
arise without apparent cause. The majority of cases have 
taken place between the ages of twenty and fort}-. 

Pathology. — The hemorrhage may be very slight, but in 
rare instances it is more extensive. It is usually limited to the 
gray matter. The diameter of the cord about the site of the 
hemorrhage is somewhat enlarged. 



66S DISEASES OF THE -NERVOUS SYSTEM. 

Symptoms. — The onset is sudden ; it may be associated 
with loss of consciousness, which is, however, of short dura- 
tion. Most often sharp pain occurs in the affected region, 
with motor paralysis. Rapid wasting is common, and the 
paralysis takes the form of paraplegia. There may be slight 
anesthesia, but, as a rule, sensibility is not impaired. The 
temperature sense is not completely lost, but it may be greatly 
impaired. 

Sequels. — Spastic paraplegia, contractures, and trophic 
changes of the skin, such as bed-sores, are common. 

Prognosis. — If the symptoms are severe, death may take 
place in a few hours, but this does not often result unless the 
hemorrhage be very profuse. If wasting and paralysis remain 
for three months, very little improvement will take place, and 
the case may die from cystitis, bed-sores, or exhaustion. 
Complete recovery is very rare, as the contractures are almost 
always present in every case. 

Treatment. — Absolute rest is necessary, and it is proper to 
have the patient lie upon the side or chest rather than upon 
the back. Ice-bags to the spine are useful. The fluid extract 
of ergot in large doses is said to have some power in control- 
ling the hemorrhage. If pain should be associated, the 
administration of opium in full doses is better treatment. 
The bowels should be kept freely open by the use of salts, 
although continued purging should be avoided. In the early 
stages of the disease electricity is contraindicated. 

ACUTE ANTERIOR POLIOMYELITIS. 

Definition. — An acute disease of childhood, also occurring 
in adults, characterized by complete loss of power in one or 
more limbs, particularly in the legs, followed by atrophy of 
the muscles, and rarely by sensory disorders, coming on 
abruptly. 

Synonyms. — Infantile spinal paralysis ; acute atrophic 
paralysis ; atrophic spinal paralysis. 

Etiology. — The disease occurs in both sexes, most often, 
however, in young children. It has shown itself in children 
as young as five months of age. The disease occasionally 
shows an epidemic character. It is more common in the 
summer months. Exposure to cold, especially during perspir- 
ation, has been supposed to be a cause, as has also trauma. 
Of late the disease has been asserted to be of an infectious 



ACUTE ANTERIOR POLIOMYELITIS. 669 

nature, due to some micro-organism. This assertion has not 
been verified. 

Pathology. — In the first stages of the disease there is 
hyperemia of the spinal membranes and of the gray matter. 
Upon microscopic examination numerous leukocytes and some 
red blood-cells are found in the affected area. There are also 
many small round cells, and the neuroglia reveals proliferative 
changes. Degenerative changes are noticed in the motor neu- 
rons.- The cells are swollen and the outline is irregular and 
the protoplasm granular. The nucleus becomes obscure. The 
degeneration may continue until the vitality of the cells is en- 
tirely destroyed, the cells becoming very granular and evacuo- 
lated and the dendrites disappearing. Interstitial changes also 
accompany those just noted. From the atrophy of the cells 
the anterior horn undergoes shrinkage, and the fibers in the 
anterior nerve-root may also undergo degeneration and atro- 
phic changes. From the extension of the atrophy, various 
groups of muscles become paralyzed. Sclerotic changes may 
also be noticed in the anterolateral column in the neighbor- 
hood of the lesion. It is believed by some that the disease is 
due to thrombosis of some of the spinal arteries or to hemor- 
rhage into the anterior horn. 

Symptoms. — As a rule, the disease begins suddenly, very 
much like an acute infectious disease, with convulsions, deli- 
rium, and fever. The temperature commonly rises to 102 F. 
or 103 F., accompanied by pain in the back and limbs, and 
occasionally by diarrhea. In rarer instances the disease is 
preceded by prodromes. In older children chill may occur at 
the onset. The temperature remains high for a few days, 
with slight morning remissions, and gradually falls to normal, 
the fever rarely lasting more than a week. Paralysis sets in 
rapidly in some instances ; the child may go to bed apparently 
healthy and awaken the following morning with paralysis. 
Occasionally there is slight rigidity in the region of the spine. 
Bed-sores and trophic changes are exceedingly rare. Pain in 
the paralyzed limb is for the most part absent ; at times slight 
pain is complained of in the region of the joints upon move- 
ment. Paralysis is usually more extensive early ; later, im- 
provement taking place. The muscles of the paralyzed limb 
soon undergo atrophy, so that there is decided change in the 
appearance of the limb within a month after the onset. The 
paralyzed limb is relaxed, never rigid, and the reaction of 
degeneration sets in rapidly. The galvanic response usually 



67O DISEASES OF THE NERVOUS SYSTEM. 

remains for some time. The circulation in the affected area is 
markedly impaired ; it becomes cold, flabby, and blue, rarely 
edematous. From disturbance of nutrition in the bone, short- 
ening occurs, which remains permanently. Paralysis most 
frequently takes place in the legs, rarely is the face affected. 
Sensation is rarely interfered with. In some instances the 
entire muscular system appears to be attacked. Reflex action 
at the level of the lesion is affected in every case. Deformities 
of the joints are common sequels. The sphincters do not 
suffer in the general process. 

Diagnosis. — Acute rheumatic fever may occasionally be 
confounded with the disease under discussion, but a careful 
examination will reveal local tenderness and pain in the joints, 
without atrophy, sweating, often some cardiac complication, all 
of which favor acute rheumatic fever. 

Prognosis. — The disease is rarely fatal, but permanent 
paralysis in some part of the body frequently remains. Some 
improvement always takes place. If the muscles respond to 
the faradic current within three weeks after the onset of the 
disease, it is likely that the case will recover. The prognosis 
is better in the cases starting acutely with fever than in those 
beginning insidiously. 

Treatment. — In the acute stage absolute rest in bed, with 
some mild counterirritant to the spine, is of use. Blistering is 
not desirable nor necessary. If the temperature is high, 
sponging with cold water and alcohol will be found effective. 
Ergot in small doses has been recommended. The iodids and 
salicylate of sodium are of some value. A mild laxative at 
the onset is useful. Late in the course of the attack, when 
paralysis begins to subside, strychnin in full doses, arsenic, 
cod-liver oil, or the hypophosphites may be beneficial. Care 
must be taken to preserve the nutrition of the muscles ; this 
may be accomplished by hydrotherapy, massage, and electric- 
ity. In chronic cases orthopedic apparatus suited to the re- 
quirements of each individual case may be used. 



ACUTE MYELITIS. 

Definition. — Acute myelitis is an inflammation of the spinal 
cord, extending longitudinally, and most often involving the 
entire transverse area. The disease may be diffuse, ascending, 
or descending. 

According to Leyden, the disease is subdivided from the 



ACUTE MYELITIS. 67 I 

following points of view : (i) From the extent and region of 
the cord involved ; (2) from the etiologic, and (3) from the 
clinical standpoint. 

Etiology. — Exposure to variations of temperature, especially 
to cold, plays an important part in the causation of the disease ; 
thus, certain occupations predispose, as those persons employed 
as engineers, cabmen, drivers, bakers, and so on. Gout, rheu- 
matism, and certain metallic poisons, such as lead, mercury, 
and arsenic, have been recognized as etiologic factors. Alco- 
hol may also be a cause. Syphilis usually gives rise to the 
chronic form. Occasionally acute myelitis may be secondary, 
resulting from extension, as in abscess, caries, or cancer of the 
spine. Traumatism is perhaps the commonest cause. The 
puerperal period and the existence of septic conditions have 
also been noted as causing the disease. 

Pathology. — The cord may be swollen, the membranes 
congested, and on section the white and the gray matter are 
with difficulty differentiated. The consistency of the affected 
part is greatly reduced. The area may be reddened, owing 
to extravasation of blood (red softening). In some instances 
the entire cord may be affected (diffuse myelitis). If the 
condition persist and fatty degeneration ensue, and the hyper- 
emia subside, the condition is then called yellow or white 
softening. Upon microscopic examination it will be found that 
the nerve-fibres are distorted and swollen. Numerous leuko- 
cytes and red blood-cells and fatty and granular cells are 
noted. The ganglion cells may also be irregular and swollen, 
their protoplasm showing degenerative changes. The nucleus 
may undergo division. 

Symptoms. — The most important symptom is paralysis of 
motion, coming on rapidly, with complete loss of sensation 
below the site of the lesion, and paralysis of the sphincters 
(bladder and rectum). Bed-sores over the sacrum, the hips, 
and the heels, with some atrophy of the muscles, develop 
rapidly, usually within a week. Some rise in temperature is 
usually present. Convulsions are not infrequent. Most com- 
monly the disease is situated in the lower dorsal region. After 
some weeks rigidity, with spasmodic jerkings upon peripheral 
irritation, occurs ; more rarely, contractions take place involun- 
tarily. Reactions of degeneration are not present. The reflexes 
are exaggerated when the lesion is above the lumbar region, and 
ankle clonus may be elicited. Loss of sensation is usually 
complete. The temperature sense is absent. Pain does not 



6j2 DISEASES OF THE NERVOUS SYSTEM. 

occur. The skin soon becomes cold, and a clammy perspiration 
appears. Usually there is some edema. If the lesion be high 
up in the cervical region, there may be pupillary changes. 

Complications and Sequels. — Cystitis is the most common 
complication. It is due to the retention of "urine in the bladder. 
Extensive bed-sores have already been referred to. Secon- 
dary pulmonary and renal complications are common, and 
amyloid disease of the kidneys sometimes occurs. 

Diagnosis. — The direct diagnosis depends on the sudden 
onset of the disease, with paraplegia, paralysis of the sphincters, 
loss of sensation, rapid trophic changes, and absence of pain 
in the muscles. 

Prognosis. — Complete recovery is rare, more or less para- 
plegia usually remaining, as secondary changes are very likely 
to occur in the cord. The greater the amount of trophic 
change, the more unfavorable the prognosis. Prolonged high 
temperature is unfavorable. Cases due to syphilis are the 
most favorable. 

Treatment. — Counterirritation by blisters or the application 
of cold are of use in the acute stage, but they are contraindi- 
cated after this stage. Precautions should be taken not to 
interfere with the nutrition of the skin, on account of the great 
liability to trophic changes. Absolute rest is important. Great 
care must be taken of the bladder ; the catheter should be 
carefully sterilized. Electricity is beneficial late in the course 
of the disease, and at this time massage is also valuable. A 
warm climate favors improvement. Hydrotherapy has been 
highly recommended. General tonics are of use. The bowels 
may be moved by enemata. In the luetic cases antisyphilitic 
treatment is indicated. 



DISSEMINATED MYELITIS/ 

Definition. — An acute disease of the spinal cord, often 
following the infectious fevers, such as smallpox and typhus, 
occasionally occurring independently of these affections. 

Synonym. — Multiple myelitis. 

Etiology. — The disease has most often been noted as oc- 
curring after the acute specific fevers, also as resulting from 
syphilis, alcohol, and exposure to cold. Occasionally the 
disease arises without assignable cause. 

Pathology. — Sclerosis is found in many parts of the white 
substance of the cord, medulla, pons, and cerebrum, and some- 



CHRONIC MYELITIS. 673 

times in the gray substance. Red softening may also be 
noted. The nerves and the nerve-cells may undergo degen- 
eration. Secondary degeneration is not often encountered. 

Symptoms. — Sometimes the disease begins acutely, so that 
within a few days or a week there is ataxia and tremor 
of the extremities, usually in both the arms and legs ; occa- 
sionally, however, this is limited to one side. There is a 
tremor of the head and of the tongue, and nystagmus is often 
present. Speech is altered ; it is often slurring, sometimes 
explosive, and occasionally scarcely intelligible. The mental 
powers are interfered with to a decided extent. The face 
becomes expressionless, and often has a foolish appearance. 
The patient is emotional, easily excited, and has lost his 
power of self-control. There is much muscular weakness, 
which is rarely so pronounced as are the tremor and the 
incoordination. The deep reflexes are exaggerated, which 
condition later gives place to spastic contractions of the 
muscles. Sensory phenomena are not marked. 

Complications. — Multiple sclerosis, optic neuritis, and some 
form of dementia are common complications. Death due to 
the disease itself is rare. 

Diagnosis. — The direct diagnosis depends upon the sud- 
denness of the onset, with the tremor and ataxia, and upon 
the mental phenomena and the course of the disease. Occa- 
sionally the disease resembles multiple sclerosis ; however, in 
this the onset is more insidious, the mental symptoms are not 
so marked, and the entire course is more nearly chronic. 

Prognosis. — Occasionally the disease may end in recovery 
after a few weeks. The prognosis, however, in general is un- 
favorable, as the disease is most likely to merge into multiple 
sclerosis. Fatal results occur from some intercurrent affec- 
tions. 

Treatment. — The treatment consists in rest in bed and the 
administration of iodid of potassium and ergot. Later, elec- 
tricity, massage, and hydrotherapy are useful. Strychnin 
should be employed only when there is rigidity of the muscles. 



CHRONIC MYELITIS* 

Definition. — Chronic myelitis results from an acute or a 
subacute attack. The disease is essentially a sclerosis of the 
spinal cord. Rarely the disease may be primary. 
43 



674 DISEASES OF THE NERVOUS SYSTEM. 

Etiology. — The disease most frequently follows an acute 
attack. Under rare circumstances the chronic condition may 
come on from the effects of trauma . or from hemorrhage, 
tumor, or caries in which destruction of the cord has occurred. 
Occasionally it is due to extension from surrounding tissues. 
In the rarest instances it is due to cold and syphilis. 

Pathology. — Sclerosis is the most important lesion. The 
nerve-cells in the gray matter become atrophied and many dis- 
appear, and the nerve-fibers may also disappear and the blood- 
vessels may show thickening. Occasionally the membranes 
are sclerotic. The ascending and descending tracts are in- 
volved in the sclerotic process. Ascending degenerations are 
noticed in the posterior columns of the cord, extending as 
far as the medulla. The degeneration involves the columns 
of Goll. Gowers' column and the cerebellar tract may also 
disclose ascending degeneration. The lateral tracts of the cord 
show the descending degeneration. 

Symptoms. — The symptoms are the same as in acute mye- 
litis, differing, however, in the fact that they come on more 
insidiously, and are often less well defined. It may be some 
months before well-marked symptoms are noticeable. There 
may be numbness and tingling, with some degree of paresthe- 
sia ; sensation, however, is rarely completely lost. The motor 
symptoms are gradual in their onset, and are rarely extreme, 
and the degree of trophic change depends upon the destruction 
of the cells in the anterior horns of the spinal cord. As the 
reflexes become exaggerated the spasticity rapidly increases. 
If degeneration in the posterior columns takes place, we find 
an increasing tendency to ataxia ; this is most often marked 
in the upper extremities. Bed-sores appear late in the disease. 
The reaction of degeneration rarely occurs, although there is 
some decrease in the quantitative response. 

Complications and Sequels. — Complications and sequels 
consist in the develdpment of bed-sores, paralysis of the 
sphincters, and cystitis. 

Diagnosis. — This is often difficult, and must at times be 
made by exclusion. It will depend upon the gradual onset 
of the symptoms just enumerated. 

Prognosis. — The disease is incurable after the symptoms 
have once manifested themselves. The course of the disease 
extends over many years, death being due to exhaustion, cys- 
titis, and bed-sores. 

Treatment. — Rest in bed is most important, improvement 



ACUTE ASCENDING PARALYSIS. 675 

first occurring from this means alone. Hot baths, electricity, 
and massage are of value. Residence in a warm climate is 
often advantageous. Iodid of potassium has been recom- 
mended, but its utility is doubtful. Everything should be 
done to maintain the general health of the patient. 

ACUTE ASCENDING PARALYSIS. 

Definition. — A disease characterized by ascending paraly- 
sis, beginning in the lower extremities and extending upward, 
later involving the respirarory muscles and the heart. 

Synonym. — Landry's paralysis. 

Etiology. — Very little is known of the causation of this 
curious disease. From its' acute onset and its course it has 
been supposed to be of an infectious nature. Occasionally 
the disease has followed exposure to cold and some one of 
the acute infections, such an enteric fever, variola, diphtheria, 
and so on. Alcohol and syphilis can not be put down as ex- 
citing factors. The disease occurs most frequently between 
the ages of twenty and fifty, the sexes being equally affected. 

Pathology. — Little is known of the pathology. Various 
lesions, such as vascular disturbances, softening, extravasation 
of blood into the gray substance, have been observed. 

Symptoms. — Prodromes commonly occur in this affection. 
Disturbances of sensation, paresthesia, and shooting pains are 
common. After a period of several days or weeks paralysis 
occurs in the lower extremities, which soon develops into com- 
plete paraplegia. The paralysis shows an ascending tendency — 
the legs first, next the body, then the muscles of the abdomen 
and back, without disturbances of respiration, and lastly there 
is paralysis of the arms. The reflexes disappear. Late in the 
course of the disease there are bulbar symptoms. There are dis- 
turbances of articulation and phonation and difficulty in chewing 
and swallowing. There are paralysis of the muscles of the eye, 
dilated pupils, increased pulse, and marked dyspnea. Death 
may take place in from two to three days, but ordinarily the 
disease lasts from one to two weeks. In some rare instances 
the paralysis shows a descending course instead of an ascend- 
ing course. As a rule, the sphincters are normal. 

Prognosis. — The prognosis is unfavorable. 

Treatment. — Such stimulants as strychnin and digitalis are 
indicated for respiratory and cardiac stimulation. Massage 
and electricity are of use. 



6y6 DISEASES OF THE NERVOUS SYSTEM. 

LOCOMOTOR ATAXIA. 

Definition. — A very frequent disease of the spinal cord, 
characterized by progressive changes, with sharp, lancinating 
pains, incoordination, and paralysis. 

The disease was systematically described by Romberg, in 
1846. 

Synonyms. — Tabes dorsalis ; posterior sclerosis of the 
spinal cord. 

Etiology. — The disease occurs most frequently in middle 
life, and particularly in the male sex. According to some 
observers, the history of syphilis is found in 90^ of the cases. 
Sexual excess, trauma, and alcoholism have all been put down 
as etiologic factors. 

Pathology. — The primary lesion is in the dorsal roots and 
in the tract of Lissauer. The extent of the sclerosis is in 
direct relationship to the duration of the disease. In the 
advanced stages it is wide-spread, so that the fasciculus of 
Goll reveals marked sclerosis in the later stages, while in the 
earlier stages this interstitial change is slight. The lesions in 
tabes are sclerosis of the posterior columns and the nerve- 
roots, degeneration of the peripheral and sensory nerves, and 
sometimes degenerative lesions of the cerebrum, optic nerves, 
and cerebellum. Even degenerative changes have been noticed 
in other sensory nerves. The cord presents marked shrinkage 
and thickening of the posterior columns, especially noted in the 
lower lumbar and dorsal regions, thinning of the posterior 
nerve-roots, and often the membranes covering the posterior 
portion of the cord are adherent. 

Symptoms. — For convenience of description the disease 
has been divided into three more or less well-defined clinical 
stages: (1) The pre-ataxic stage; (2) the ataxic stage; and 
(3) the paralytic stage. 

The Pre-ataxic Stage. — The symptoms which first call 
attention to the disease are the so-called " lightning pains." 
They are sudden in onset, sharp and shooting in character, 
and only momentary in duration. They frequently occur in 
paroxysms. Occasionally the pain is present in but one leg ; 
at other times it is distributed, shifting its location rapidly. 
These pains arise most frequently in the lower extremities, 
occasionally in the upper, more rarely in the face. Dampness 
and cold aggravate the pain, so that the disease has commonly 
been mistaken for forms of so-called chronic rheumatism. 



LOCOMOTOR ATAXIA. 677 

Slight cutaneous hyperesthesia often arises early in connection 
with this pain. Eye symptoms are very common in the first 
stage. There may be optic nerve atrophy, diplopia, strabismus, 
or ptosis due to some oculomotor palsy. The most important 
ocular phenomena relate to the pupil, which reacts to accommo- 
dation, but not to light. This is known as the " Argyll Robert- 
son pupil." The pupil is most often small, and is called 
the " pin-point " pupil. Occasionally inequality in size occurs. 
Soon there may be slight difficulty in micturition. The early 
important symptom is the loss of the tendon reflex, the elec- 
tric reaction of the extensor muscles remaining normal. The 
loss of the knee-jerk in tabes is known as WcstphaV s sign. In 
some rare instances the knee-jerk is preserved. The com- 
bination of the three symptoms — lightning pain, absence of 
tendon reflex, and eye phenomena — warrants a diagnosis of 
locomotor ataxia. 

The second stage is noticed upon the occurrence of ataxic 
symptoms. By ataxia, or incoordination, is meant a want of 
harmony in muscular contraction as distinguished from a loss 
of power in the muscles. These symptoms first show them- 
selves in walking or standing, beginning as a mere unsteadi- 
ness, which is increased by the patient closing his eyes. An 
early sign of which the patient complains, is that he can not 
walk in the dark. This incoordination steadily increases, so 
that occasionally when he attempts to turn, the feet are 
crossed. The ataxic gait soon manifests itself: the patient 
walks with his feet wide apart, soon depending upon a stick 
for support ; he lifts the advancing foot high, throwing it out- 
ward with a jerky movement and bringing it down with a 
sudden stamp. When sitting, the patient often may not be 
able to describe a circle with his toe, and can not touch one 
knee with the opposite heel. When put in the erect posture 
with his feet close together and his eyes closed, he sways 
markedly ; this being known as Romberg 's symptom. Later 
in the disease he can not stand without support, and the inco- 
ordination may spread to the upper extremities. Soon it is 
impossible for the patient to execute the finer movements with 
the hands ; thus, he can not pick up a pin from the table, he 
fails to button his coat, especially if his eyes are closed, he 
may not be able to touch the tip of his nose with his fingers, 
etc. By this time, as a rule, defects of sensation occur ; there 
are tingling, a sensation of pricking by pins and needles, and 
numbness in the lower extremities, the patient often feeling 



6 7 8 DISEASES OF THE NERVOUS SYSTEM. 

as if he were walking upon thick carpet or upon cotton. A 
peculiar sensation is felt around the waist, as if there were a 
tight girdle worn ; this is known as the " girdle pain" Anes- 
thesia may now be present in various parts of the body ; often 
there is analgesia, the patient not feeling the prick of a pin, the 
pain being markedly delayed. The symptoms of the first 
stage, as a rule, all continue throughout the second stage. 

The third stage shows an aggravation of all the symptoms 
of the second stage, the patient often becoming quite helpless. 
There may be true paraplegia and paralysis of the sphincters, 
bladder, and rectum. The patient is now confined to bed or 
to a chair, becomes emaciated and feeble, bed-sores develop, 
cystitis is common, and intercurrent diseases may appear. 

Description of Special Symptoms. — Motor Phenomena. — 
One of the earliest symptoms is often a disproportionate fatigue 
following slight exercise, accompanied by weakness in the legs. 

Sensory Affections. — Hyperesthesia, analgesia, and par- 
esthesia occur. Analgesia of the ulnar nerve particularly has 
been noted. 

Visceral Crises, — These consist in a violent and sudden 
disturbance of the function of an organ, for which no sufficient 
cause can be given. The most frequent of these is the gastric 
crisis. This shows itself by a concentrated pain in the epi- 
gastrium, with severe and uncontrollable vomiting. The 
tongue is usually clean, the pulse frequent, and the tempera- 
ture remains normal. These symptoms may be followed by 
severe nervous depression, and often by collapse. In a day or 
two the vomiting suddenly ceases, the patient being apparently 
restored to his normal health. After a variable period the 
attack recurs, being characterized in some cases by quite 
remarkable periodicity. As a rule, gastric crises occur early 
in the disease, and pass off as the disease advances. When 
the patient is questioned about these manifestations, he is apt 
to describe them as bilious attacks. Intestinal crises may be 
associated with the gastric crises, or occur independently. 
Similar conditions may arise in the region of the kidney, 
urethra, and bladder. The sexual function is often interfered 
with ; it is sometimes exaggerated, and at other times entirely 
lost. Similar crises appear in the larynx, and are known 
as laryngeal crises, in which paroxysmal cough and dyspnea 
occur. Laryngeal crisis may be accompanied by coma or 
convulsions. Occasionally there is paralysis of the vocal 
cords. 



LOCOMOTOR ATAXIA. 679 

Symptoms Referable to the Circulatory System. — In- 
creased pulse frequency is a common symptom of tabes. 
Attacks which simulate angina pectoris occur, and are known 
as cardiac crises. Occasionally the symptoms of Graves' dis- 
ease have been associated with tabes. Organic disease of the 
aortic valve is sometimes associated. 

Trophic Lesions. — Charcot called attention to arthropathies, 
and the name " Charcot's joints" has been applied to the 
peculiar formations appearing at the joints in tabes. Any joint 
may suffer, but the large joints are more frequently attacked 
than the small ones, the knee-joints being the most commonly 
affected. The joint suddenly becomes swollen, and upon 
examination shows a large effusion. There is neither heat, 
tenderness, nor pain ; occasionally new bone is developed 
and restrictions of movement occur. The joint rarely sup- 
purates, but remains permanently enlarged. Degeneration 
of the arterial structures, bones, cartilages, and muscles is 
permanent. Great liability to fracture of the bones, especially 
the long bones of the extremities, has been noted in tabes. 
In some cases rupture of the tendo Achillis has been 
observed. Perforating ulcer of the foot is common, and is 
diagnostic. Anesthesia in the neighborhood of the ulcer is 
usual. Occasionally gangrene results. Deformity and loss 
of nails are common. Herpes sometimes occurs in the course 
of the lightning pains. Purpuric manifestations in the form 
of small subcutaneous ecchymoses are not infrequent. 

Mental Affections. — In the majority of cases the mind is 
not affected. In rare instances mania may occur, and the 
form of general paralysis known as "tabes of the brain " has 
been noted. 

Course of the Disease. — The course of the disease, as a 
rule, is slow, but progressive. The stages are measured by 
years rather than by months. Sometimes an apparent inter- 
mission takes place. It is very unusual for locomotor ataxia 
to run a rapid course, although cases that have lasted only a 
few weeks or a few months have been noted. 

Diagnosis. — The diagnosis in a well-marked case is easy. 
Scarcely any other affection can be confounded with locomotor 
ataxia if the picture be typical. It must be differentiated 
from paraplegia, cerebellar disease, syringomyelia, and hys- 
teria. 

Prognosis. — The prognosis as to cure is extremely unfavor- 
able. The duration of life is not always shortened by loco- 



680 DISEASES OF THE NERVOUS SYSTEM. 

motor ataxia. Death may occur at any time from intercur- 
rent affections. As a rule, optic nerve atrophy renders the 
prognosis of the spinal symptoms more favorable. 

Treatment. — The treatment of locomotor ataxia is ex- 
tremely unsatisfactory. It is impossible to prevent the devel- 
opment of the successive stages. Attention should be given 
to the general health and hygiene of the patient. For the 
relief of the lightning pains, antipyrin and drugs of this class 
are valuable ; ten-grain doses repeated three or four times in as 
many hours usually afford prompt alleviation. For the crises 
morphin hypodermically is the only reliable agent. Hydro- 
therapy gives immediate relief in some cases. Electricity is 
also useful. Absolute rest in bed for a prolonged period of 
time has been urged by many authorities, especially during 
the time in which the lightning pains are severe. Good re- 
sults may be obtained by the administration of the double 
chlorid of gold and sodium. In the majority of cases anti- 
syphilitic treatment is valueless. When the use of the catheter 
becomes necessary, strict antisepsis must be insisted upon. 
The diet throughout the course of the disease should be liberal, 
attention being given to the condition of the bowels. The 
treatment by suspension is of value in some cases. 

PRIMARY LATERAL SCLEROSIS. 

Definition. — A chronic disease of the spinal cord, due to 
sclerosis of the descending fibers of the crossed pyramidal 
tracts, with marked symptoms referable to the nervous system. 

Synonyms. — Spastic paraplegia ; spastic spinal paralysis ; 
Erb's palsy. 

Etiology. — The disease is most common in adults between 
the ages of twenty and forty, both sexes being equally affected. 
Infective processes, sexual excess, syphilis, and lead-poisoning 
have been designated as etiologic factors. It is more common 
in neurotic families. 

Pathology. — In this disease the crossed pyramidal tracts 
reveal sclerotic changes. The multipolar cells in the anterior 
cornua may be involved in the sclerotic process. Disseminated 
sclerosis may follow lateral sclerosis. 

Symptoms. — The disease begins insidiously with symptoms 
of fatigue upon slight exertion, and there is some alteration in 
the gait. The knee-jerks are markedly increased. These 
symptoms progress in severity until the fatigue is so great 



POSTEROLATERAL SPINAL SCLEROSIS. 68 1 

that the patient walks with much difficulty. When he 
attempts to walk, the muscles are drawn into a state of 
extreme tension. Clonic spasms are apt to occur in the feet 
and legs, especially when the patient is in the recumbent 
posture. Besides the increased knee-jerk, ankle clonus is 
present. The disease may extend high up in the cord and 
affect the upper extremity. The skin reflexes are also 
increased. Other functions of the nervous system are not 
impaired. The movement of the patient becomes difficult 
on account of the spasmodic condition of the limbs. Walk- 
ing is performed slowly and with effort. The feet can not 
be lifted clear of the ground, and so the front part of the 
foot is dragged with each step. This often shows itself in 
examining the shoe. In the later stages of the disease it is 
impossible for the patient to walk at all. 

Prognosis. — The prognosis is unfavorable. The condition 
is incurable. 

Treatment. — The treatment is the same as in other forms 
of cord disease. Warm baths have been highly recommended 
to relieve the spastic condition of the muscles. A good 
general diet is of use. General tonics such as cod-liver oil, 
hypophosphites, and arsenic may be of value. If syphilis be 
suspected as a causative factor, mercury and iodid of potassium 
should be tried. 



POSTEROLATERAL SPINAL SCLEROSIS. 

Definition. — A sclerosis of the posterior and lateral columns 
of the spinal cord, with symptoms of lateral sclerosis, mostly 
preceded and generally accompanied by those of sclerosis of 
the posterior columns of the cord. 

Synonyms. — Progressive spastic ataxia ; ataxic paraplegia. 

Etiology. — The disease occurs most frequently between 
the ages of thirty and fifty, and is more common in men than 
in women. Little is known of the etiology. 

Pathology. — Very often this disease represents an exten- 
sion of the sclerotic process of tabes into the lateral columns, 
or it may be secondary to myelitis. 

Symptoms. — The symptoms are those of spastic paraplegia 
combined with incoordination. The onset is insidious. All 
the symptoms of spastic paraplegia occur, but as the spastic 
phenomena become marked in the lower extremities, the 
signs of incoordination also appear. The gait has the 



682 DISEASES OF THE NERVOUS SYSTEM. 

combined qualities of locomotor ataxia and lateral sclerosis. 
The reflexes are most often increased. Ankle clonus may be 
present. Lightning pains are, as a rule, absent. Anesthesia 
does not occur. The Argyll Robertson pupil is rarely present. 
Later in the course of the disease the spastic phenomena be- 
come more prominent, so that the case is often mistaken for one 
of advanced lateral sclerosis. If the ataxic phenomena are 
more prominent, the knee-jerks may disappear and the case 
more closely resemble tabes. The symptoms, after they have 
involved the lower extremities, gradually extend to the upper 
extremities. 

Prognosis. — The course of the malady is progressive, 
although slow. 

Treatment. — The treatment is the same as that described 
for sclerosis of the cord in general. 



PUTNAM AND DANA'S COMBINED SCLEROSIS OF 
THE LATERAL AND POSTERIOR COLUMNS* 

This disease consists in a subacute sclerosis of the lateral 
and posterior columns of the cord, in which softening finally 
occurs at certain levels. It is characterized by symptoms of 
spastic paraplegia, but develops with more rapidity, death 
taking place much more speedily than in other forms of 
sclerosis. 

Etiology. — The disease is said to be due to chronic lead- 
or arsenic-poisoning. It is more common in women, and may 
be associated with pernicious anemia. 

Pathology. — The lesions are those of the rapidly progress- 
ing sclerosis of the lateral and posterior columns, accompanied 
by an acute inflammation of the substance of the cord. 

Symptoms. — The disease begins with numbness and 
tingling in the extremities, particularly in the feet, with great 
emaciation and anemia ; obstinate diarrhea is often present. 
The first symptom referable to the nervous system may be 
paraplegia. The knee-jerks are exaggerated and ankle clonus 
is present. The lower extremity is much more frequently 
affected than the upper. Girdle and lightning pains are rarely 
present. There are no eye symptoms. The disease proves 
fatal in two years from its commencement. 

Prognosis. — The prognosis is absolutely unfavorable. 

Treatment. — The treatment should be palliative. 



HEREDITARY ATAXIC PARAPLEGIA. 683 



PELLAGRA. 

This is a rare disease in this part of the world, but occurs 
in parts of Italy, France, and Spain. In this disease the ana- 
tomic changes show a degenerative process in the posterior 
and lateral columns of the spinal cord, associated with atrophy 
of the large cells in the anterior horns. There is also a scle- 
rosis of the pia mater, and occasionally there is a formation 
of bony plates in the arachnoid. Pellagra is said to be due 
to poisoning from diseased maize. The symptoms are those 
of ataxic paraplegia associated with marked wasting. 



HEREDITARY ATAXIC PARAPLEGIA. 

Definition. — A rare disease of the spinal cord occurring in 
families, especially in young individuals, characterized by 
paraplegia and accompanied by changes in the lateral and 
posterior columns of the spinal cord. 

Synonym. — Friedreich's ataxia. 

Etiology. — The occurrence of two or more cases in one 
family is characteristic. The consanguinity of parents has been 
traced in a certain proportion of cases as a cause of the dis- 
ease. The sexes are equally affected. The disease may affect 
only one sex in a family to the exclusion of the other. The 
acute infectious diseases have been given as etiologic factors. 
Ten cases have been known to occur in the same family. 

Pathology. — Little is known of the pathology in this con- 
dition. In many cases reduction in the diameter of the spinal 
cord is noted, probably due to hypoplasia or atrophy, the latter 
being the result of fibrous connective-tissue contraction, for in 
nearly all cases fibroid changes are noted, particularly of the 
posterior columns. The direct cerebellar tract or direct pyram- 
idal tract, the lateral pyramidal, and the tract of Lissauer are 
sometimes involved. The cells in the anterior and posterior 
horns of the columns, as well as the cells of Clarke, may be 
atrophied. 

Symptoms. — The first symptoms occur at any time from 
the second to the twenty -fourth years. In the majority of cases 
they appear between the sixth and the fifteenth years. Several 
members of the same family may be affected. Rarely isolated 
cases occur. The symptoms are those of spastic paraplegia 
and locomotor ataxia, with marked wasting. Irregular move- 



684 DISEASES OF THE NERVOUS SYSTEM. 

ments may take place in the limbs, even when the patient is at 
rest. Speech becomes impaired early ; it is thick and monot- 
onous, and sounds as though the patient had a foreign body in 
his mouth. Occasionally there are jerky movements in the 
tongue. The face is expressionless, but the intellect is un- 
affected. Nystagmus is a common symptom. The pupillary 
reactions are normal. The deep reflexes are absent from the 
beginning of the attack. Sensory symptoms are rare. A 
peculiar deformity of the foot occurs, known as the " pes 
cavus," consisting of a peculiar stumpy and jerky appearance 
from before backward, in which the arch is markedly exagger- 
ated, the toes being extended ; the great toe is unusually 
prominent. A similar deformity sometimes occurs in the 
hand, known as " man us cava." Death may result from mal- 
nutrition or from intercurrent diseases. 

Prognosis. — The prognosis is unfavorable. 

Treatment. — The treatment is the same as in other forms 
of sclerosis. 



AMYOTROPHIC LATERAL SCLEROSIS. 

Definition. — The disease is characterized by a chronic pro- 
gressive muscular atrophy, usually at first limited to one part 
of the body, most often the upper extremity, gradually spread- 
ing and involving other parts. 

Synonyms. — Spinal muscular atrophy ; wasting palsy. 

Etiology. — It attacks the patient between the ages of 
twenty-five and fifty, usually when over thirty. Women are 
more often affected than men. Scarcity of food, exposure to 
cold, and injuries to the back have been given as etiologic 
factors. 

Pathology. — The changes are similar to those found in in- 
fantile spinal paralysis, atrophy of the ganglion cells in the an- 
terior horns and sclerosis of the lateral columns are found. It 
is a degenerative process. The dorsal and lumbar regions, but 
especially the cervical, are affected. The anterior root-fibers 
are atrophied and the anterior commissure is degenerated. 
Degenerated fibers are also found in the peripheral nerves 
with atrophy of the muscles. 

Symptoms. — Gradual wasting of the muscles is. the most 
striking symptom of this disease. In 90^9 of the cases the 
muscular atrophy begins in the arms, and particularly in the 
hands, or in the muscles of the shoulder. When the atrophy 



HEREDITARY FORMS OF PROGRESSIVE ATROPHY. 685 

begins in the muscles of the hand, the thenar and hypothenar 
eminences (thumb and little finger) are first affected, which 
is a striking feature of this disease. Usually the atrophy 
is unilateral, especially at the beginning of the malady, 
and it may be a year or more until the other side becomes 
affected. The atrophy soon spreads to the other muscles, 
such as the muscles of the back and neck. If the respira- 
tory muscles atrophy, life is shortened. In rare instances 
the atrophy may begin in the lower extremity. Loss of 
power is always marked, and is proportionate to the degree 
of wasting. Fibrillary contraction commonly occurs in the 
atrophied muscles. This is quite characteristic. When the 
wasting in the muscles is rapid, there may be partial or 
complete reactions of degeneration. The tendon reflexes are 
exaggerated ; if wasting occurs in the lower extremity, the 
knee-jerk is lost. Occasionally there are rigidity and a spastic 
condition of the muscles. The affected muscles are flaccid 
when not in a spastic condition. All grades of atrophy 
may occur in different cases. The sphincters, as a rule, are 
unaffected. The sexual power is frequently lost. 

Prognosis. — The prognosis both as to life and improvement 
of the wasted muscles is grave. It may prove fatal in less 
than a year from the onset, or it may last for fifteen or twenty 
years. The ordinary duration is from three to five years. If 
the disease shows a rapid onset, the course is liable to be 
short. The chief danger to life is due to involvement of 
the muscles of respiration and to bulbar paralysis. 

Treatment. — Gowers favors the injection of nitrate of 
strychnin into the muscles, beginning with the minimum and 
rapidly increasing to the maximum dose. Fowler's solution 
should be given by the mouth. Electricity ought not to be 
employed. Massage and passive movements are said to be 
of service. The patient should be placed amid the best 
hygienic surroundings. 



HEREDITARY OR INFANTILE FORMS OF PROGRESSIVE 
ATROPHY OF SPINAL ORIGIN. 

Werding and Hoffmann have reported cases in which sev- 
eral children in the same family were affected during the first 
year of life by weakness and symmetric wasting in the mus- 
cles of the legs and back, extending upward. The paralysis 
was of the flaccid type, and accompanied by reactions of 



686 DISEASES OF THE NERVOUS SYSTEM. 

degeneration, absence of knee-jerks, and incomplete loss of 
the skin reflexes. Lordosis of the lumbar spine was present, 
and some bulbar symptoms were noted. There was no pain 
or tenderness. There were no alterations of sensibility. The 
mental power was well preserved and the sphincters were 
normal, death taking place in a few years from involvement 
of the muscles of respiration. The following pathologic 
lesions were noted : A degenerative atrophy of the ganglion 
cells of the anterior horns ; marked degeneration of the an- 
terior nerve-roots ; degeneration of the mixed nerves ; and 
secondary atrophy of the muscle -fibers, with" an increase of 
the nuclei of the sarcolemma. This has been regarded as a 
separate type. 

PROGRESSIVE MUSCULAR ATROPHY OF THE HEUBNER- 
STRUMPELL VARIETY. 

The same symptoms occur in this variety as in the form 
already described, except fibrillary contraction of the muscles 
and the appearance of the reactions of degeneration. Occa- 
sionally even some of the muscle-fibers show hypertrophy. It 
has been asserted that in these cases the changes in the spinal 
cord are secondary to those in the muscular system. It is 
still a question whether this disease is a nosologic entity. 



DISSEMINATED SCLEROSIS. 

Definition. — A sclerosis of parts of the brain and spinal 
cord, with characteristic phenomena. 

Synonyms. — Multiple sclerosis ; insular sclerosis ; cerebro- 
spinal sclerosis. 

Etiology. — The disease occurs in early adult life. It is 
rare after the age of forty. It probably appears more often 
in females than in males, and it has been supposed that the 
disease is more likely to arise in females with a neurotic ten- 
dency. It may follow chronic lead-poisoning and the excessive 
use of alcohol. The acute infectious diseases also appear to 
have some causative relation. Cold, exposure, trauma, and 
fatigue have been found to precede many cases. 

Pathology. — Sclerotic areas are found in various parts of 
the nervous system, particularly the central nervous tissue, 
sometimes the cranial and other nerves. The sclerotic tissues 



DISSEMINATED SCLEROSIS. - 68? 

are represented by reddish-gray patches or very firm areas of 
a lighter color. The cord, the pons, the crus, the cerebrum, 
and the cerebellum have all been found involved. Upon con- 
traction of the fibrous connective tissue atrophy of the nerve- 
tissues ensues. The blood-vessels frequently reveal sclerotic 
changes. 

Symptoms. — Three distinct types of this disease have been 
described : The cerebrospinal, the cerebral, and the spinal. In 
the majority of cases, however, the disease involves both the 
brain and the spinal cord ; and hence the predominant type is 
the cerebrospinal. The first symptoms may appear after some 
mental or physical strain, the patient behaving as if affected 
by hysteria. There may be temporary aphonia, from which 
there may be speedy recovery, or numbness may occur in 
some part of the body. There may also be a sensation of 
deadness and of coldness, a feeling as of the pricking of 
pins and needles, or there is great loss of power in some 
part of the body, even with convulsions. These symp- 
toms may disappear for a time and reappear with increased 
severity. When the disease has been fully established, 
periods of remission may occur. A common type of the 
disease as described by Charcot shows the following symp- 
toms : The patient develops spastic paraplegia, with exagger- 
ated reflexes, with ankle clonus, and limited movements. An 
irregular jerky tension tremor occurs, nystagmus being a 
prominent symptom. Diplopia and paralysis of the ocular 
muscles are common. Scanning speech is prominent. There 
are paresthesia, tinnitus aurium, and vertigo. The mental 
faculties are blunted, and in some few cases apoplectiform and 
epileptiform convulsions- may appear. Trophic changes arise 
late in the disease, the sphincters, however, remaining normal. 
Another variety of the disease is one in which the symptoms 
are more closely referable to the spinal cord, in which the 
cerebral manifestations, such as the vertigo and apoplectic 
attacks, the ocular symptoms, scanning speech, tension tremor, 
and so on, do not occur. Rarely are the knee-jerks absent. 

Prognosis. — The prognosis is unfavorable. The disease 
may last for a long time. The cases in which the spinal 
symptoms alone are present may last for twenty years or 
longer. 

Treatment. — The treatment is the same as in other forms 
of sclerosis. The salts of gold, silver, and arsenic have been 
recommended. 



688 DISEASES OF THE NERVOUS SYSTEM. 



TUMORS OF THE SPINAL CORD. 

Tumors may arise from the membrane and from the cord 
substance. The following tumors have been found arising 
from the membranes : Lipomata, myxomata, enchondromata, 
fibrolipomata, sarcomata, and carcinomata. Sarcomata, as a 
rule, are primary, but carcinomata are always secondary. The 
tumors arising from the cord substance are, as a rule, primary, 
the following having been noted : Myxomata, fibromata, psam- 
momata, sarcomata, fibrosarcomata, angiosarcomata, neuro- 
mata, and lipomata. Echinococcus cysts have also been 
found. As a rule, but one tumor has been found. Sarcoma 
and neuroma have occasionally been found multiple. Gum- 
mata have been noted. It is supposed that trauma may have 
some influence in the production of new growths. 

Symptoms. — The symptoms are those of compression and 
local irritation. At first the pain is local, associated with 
stiffness ; later, atrophic paralysis associated with anesthesia 
and hyperesthesia occurs. Spasms with exaggerated reflexes 
and disturbance of sensibility are common. Paraplegia with 
paralysis of the sphincters is a late symptom. 

Prognosis. — The prognosis is unfavorable, except in the 
cases of gummata. 

Treatment. — If the disease be of syphilitic origin, iodid of 
potassium and mercury are of use. Surgical interference is 
often indicated. For the pain opium and counterirritation are 
necessary. 

SYRINGOMYELIA. 

Definition. — Syringomyelia is characterized by the forma- 
tion of a cavity in the substance of the spinal cord owing to 
the breaking-down of certain nerve-structures. 

Synonym. — Gliosis spinalis. 

Etiology. — The disease may begin after severe trauma to 
the spine. Some cases have been known to follow the infec- 
tious fevers, especially enteric fever, most cases, however, oc- 
curring between the twentieth and thirtieth years of life, and 
being slightly more common in males than in females. Nothing 
is definitely known of the etiology. 

Pathology. — This disease is regarded as a gliosis with degen- 
eration of the central portion of the cord and hemorrhages, so 
that a cavity is formed in the central portion of the cord. It is 
to be distinguished from hydromyelia, which simply refers to 



SYRINGOMYELIA. 689 

a distention of the central portion of the canal. The cavity 
in the cord in syringomyelia may involve the entire length, but 
more frequently it is localized to certain areas. The cavity 
formation frequently involves the upper part of the cord, 
the cervical and thoracic regions. A brownish gelatinous 
fluid is sometimes contained in the central portion of the 
cord. 

Symptoms. — The recognition of the disease depends upon 
the association of three important symptom groups : (i) Loss 
of the sensations of pain and temperature in any part of the 
body, the tactile sense being preserved in the same area ; (2) 
trophic changes in the skin, muscles, bones, or joints ; (3) 
progressive muscular atrophy, with paralysis. With these 
symptoms there may be associated spastic paraplegia or the 
symptoms of a transverse myelitis or the symptoms relating 
to involvement of the lateral, posterior, or all the columns of 
the spinal cord. The prominence of the symptoms will depend 
upon the distribution of the lesion. The course of the disease 
is chronic, the symptoms appearing gradually, and remaining 
stationary for years, death being due to some intercurrent 
affection, although in. rare instances death has occurred from 
the rupture of the cavity. In a large number of cases there 
is marked curvature of the spine, either laterally or forward 
or occasionally even backward. The disease formerly called 
Morvan's disease is now known to be a variety of syringo- 
myelia, as in all cases examined after death the cavity has 
been found in the spinal cord. The reflexes vary ; they may 
be either lost or exaggerated, depending upon the situation 
of the lesion ; and if the disease extend to the medulla, im- 
plication of the cranial nerves occurs. 

Prognosis. — The prognosis is unfavorable, the disease 
lasting for many years. 

Treatment. — The treatment is symptomatic. If the paral- 
ysis occurs, it should be treated as an anterior poliomyelitis. 
If there are marked trophic changes, they should be treated 
by rest, by mechanical appliances, and by surgical means. 
The sensory loss can not be remedied. Tonics may be 
necessary. 



44 



69O DISEASES OF THE NERVOUS SYSTEM. 



DISEASES OF THE MEDULLA AND PONS. 

PROGRESSIVE BULBAR PARALYSIS* 

Definition. — A disease of middle age, characterized by im- 
pairment of speech, phonation, mastication, and deglutition, 
which is both gradual and progressive, with increasing mus- 
cular atrophy. 

Synonyms. — Labioglossolaryngeal paralysis ; chronic bul- 
bar paralysis ; Duchenne's disease. 

Etiology. — This disease rarely occurs before the forty-fifth 
year of life, and is more common in the male sex. It is sup- 
posed that lead-poisoning and diphtheria may give rise to it. 
Exposure to cold, trauma, and syphilis have been named as 
etiologic factors. 

Pathology. — The muscular atrophy is limited to the lips, 
tongue, palate, and muscles of the larynx, and if spinal 
atrophy be associated, the muscles of the neck, shoulders, or 
arms are also involved in the process. The tip of the tongue 
frequently reveals very marked atrophy. The roots of the hypo- 
glossal, glossopharyngeal, vagus, facial, the motor nucleus 
of the fifth, and spinal accessory may show distinct atrophy. 
They are of a grayish-red color and very much thinned. 
Changes are also encountered in the medulla oblongata. 
The ganglion cells in the motor nuclei are atrophied. The 
most marked atrophy is found in the nuclei of the hypo- 
glossal, and is less marked in the nuclei of the vagus and 
spinal accessory. Changes have also been noted in the cord. 

Symptoms. — The first signs of the disease are some in- 
volvement of the tongue, so that speech becomes indistinct, 
especially in the use of the Unguals, such as " 1 " and " n." The 
lips soon become weak, and the patient has difficulty in pro- 
nouncing the labials. Whistling is impossible. Next the 
muscles of the pharynx and palate suffer. Saliva dribbles 
from the mouth ; the face becomes motionless and without ex- 
pression. Speech becomes impossible. There is total inability 
to swallow. Some atrophy of the muscles of the face also 
takes place. Sensory phenomena are not present ; however, 
the throat reflexes are early lost, so that food finds its way into 
the larynx. There are slight, if any, changes in the electric 
reactions. The mind is not impaired ; the patient, however, 
is apt to be emotionless. Progressive muscular atrophy is a 



HEMORRHAGE INTO THE MEDULLA AND PONS. 69 1 

common association. The advance of the disease is progres- 
sive, although there may be periods of intermission lasting 
some weeks or months. The duration of the disease varies 
from six months to nine or ten years, the majority of cases 
lasting from two to four years. 

Prognosis. — The prognosis is unfavorable, especially so if 
the disease show itself early in life. The principal causes 
of death are inanition, bronchopneumonia (deglutition pneu- 
monia), failure of respiration, and intercurrent diseases (croup- 
ous pneumonia). 

Treatment. — The general health of the patient must be 
maintained. Tonics, such as arsenic, iron, and strychnin, are 
useful. Great care must be taken to prevent food from find- 
ing its way into the larynx. In the later stages of the disease 
morphin hypodermically should be used to make the patient 
comfortable. 



HEMORRHAGE INTO THE MEDULLA AND PONS. 

Hemorrhage into the medulla and pons frequently occurs 
by extension or from the rupture of a bulbar blood-vessel. 

Etiology. — Hemorrhage in this locality is due to the same 
causes that give rise to hemorrhage in general. Hemorrhage 
into the medulla is rare, and into the pons is also very rare 
as compared with hemorrhage into the internal capsule. 

Pathology. — The causes of this condition are similar to 
those of cerebral hemorrhage, and it may result from trauma, 
miliary aneurysms, meningitis, syringomyelia, or tumors. 

Symptoms. — As a rule, death occurs very rapidly — in 
from a few seconds to a few minutes — from interference with 
the cardiac and respiratory nuclei. There is loss of con- 
sciousness, most often without convulsions. In the rarest 
instances recovery may follow with symptoms of bulbar 
paralysis. When convulsions occur, they commonly begin at 
the onset of the affection. They are usually general and epi- 
leptiform in character, but the legs alone may be affected. 
Paralysis is often bilateral ; rarely hemiplegia occurs. The 
pupils are " pin-point," but in rare instances may be dilated. 
Vomiting is common, the temperature is high, — from 105 F. 
to 106 F., — and the respiration is of the Cheyne-Stokes 
type. 

Prognosis. — Recoveries are extremely rare. At least four- 
fifths of all cases are fatal. It should alwavs be borne in 



692 DISEASES OF THE NERVOUS SYSTEM. 

mind that if recovery takes place, secondary attacks are most 
likely to occur. 

Treatment. — The treatment is that of cerebral hemorrhage. 
(See p. 699.) 



DISEASES OF THE BRAIN. 

EXTERNAL PACHYMENINGITIS. 

Etiology. — This is an exceedingly rare disease, occurring 
especially as a so-called idiopathic affection. It usually follows 
trauma to the skull, diseases of the bones, or inflammatory 
conditions of the muscles or other parts covering the bone. 
Concussion of the head may also give rise to it. As a rule, 
there is an exudation of blood from vessels that are engorged 
between the dura mater and the bone. 

Symptoms. — The symptoms are those of cerebral com- 
pression. Only from these symptoms is it possible to arrive 
at a diagnosis. The condition, as a rule, belongs to the 
domain of surgery. Occasionally pus formation takes place, 
and in this way the pia-arachnoid may become affected, and 
leptomeningitis develop. 

Treatment. — If a purulent inflammation can be diagnosti- 
cated, the trephine must be used as early as possible. Mer- 
cury and iodic! of potassium have been advised. 

INTERNAL PACHYMENINGITIS. 

Synonyms. — Hemorrhagic pachymeningitis ; hematoma of 
the dura mater. 

This condition of the meninges consists of newly developed 
fibrous connective tissue between the dura and the internal 
membranes. Numerous hemorrhages into this new-formed 
membrane are found, some of which are very minute ; again, 
very large extravasations of blood are found, hence the name 
"hematoma of the dura mater." The lesion at first always 
attacks the dura at the point where the hemorrhage arises ; 
it is associated with diseases of the blood-vessel walls, such, 
as atrophic changes of the vessels, with chronic alcoholism, 
senile dementia, and dementia paralytica. The lesion is 
usually bilateral, and very often situated in association with 
the parietal bones. 

The condition has been observed as occurring with senile 



ACUTE LEPTOMENINGITIS. 693 

changes, also with leukemia, pernicious anemia, and diseases 
of the heart. 

The symptoms are by no means characteristic. There 
may be headache, dizziness, and sometimes convulsive move- 
ments. If the hemorrhage be large, symptoms of pressure arise. 

Treatment. — The treatment is not at all satisfactory. 
General tonics are of use. If the hemorrhage be extensive, 
surgical treatment may serve to benefit the patient. 

ACUTE LEPTOMENINGITIS. 

Synonym. — Inflammation of the pia-arachnoid. 

Etiology. — This condition most frequently arises from ex- 
tension of adjacent points of infection to the pia and arach- 
noid. Caries of the bones of the skull is a common cause, 
and thus micro-organisms gain entrance. The disease most 
frequently arises from the temporal bone, especially from 
middle ear disease, and often as a result of an otitis media. 
Infection may occur from diseases of the sinuses, such as the 
frontal, the ethmoidal, and the sphenoidal. Trauma is a 
common cause. Acute leptomeningitis may develop during 
the course of erysipelas, pneumonia, septicemia, enteric fever, 
scarlet fever, measles, ulcerative endocarditis, acute rheumatic 
fever, and sometimes in some of the chronic diseases, such as 
gout, arteriosclerosis, and renal disease. 

Pathology. — The lesion maybe diffuse or localized to cer- 
tain areas. Unilateral disease often is due to extension from 
middle ear disease. The exudate varies from a fibrinous to a 
purulent one, and in some cases may be hemorrhagic. Vari- 
ous micro-organisms have been associated with this disease, 
particularly the pneumococcus, the streptococcus, the staphylo- 
coccus, the gonococcus, the bacillus typhosus, and the bacillus 
coli communis. 

Symptoms. — As a rule, headache is a prominent symp- 
tom in this affection ; this is usually continuous and severe. 
Generally vertigo is present. Delirium soon manifests itself, 
and may alternate with coma. There is "photophobia and 
great aversion to the slightest sounds, even while the patient 
is sleeping or partly somnolent. There is general cuta- 
neous and muscular hyperesthesia. Vomiting of the cere- 
bral type is common. If pus-formation takes place, chills 
occur followed by fever of a septic type. The temperature 
may be normal or, under exceedinglv rare circumstances, 



694 DISEASES OF THE NERVOUS SYSTEM. 

subnormal. In young children hyperpyrexia is common and 
the pulse-rate is very rapid, but there is no proportion between 
pulse and temperature. Occasionally there is bradycardia. 
Convulsions are common, and they may affect the muscles 
of the face or of the extremities. Painful contractions of 
the muscles of the back of the neck are frequent in basilar 
meningitis. The belly wall is often rigid and the abdomen 
may be retracted. If the membranes at the base of the 
brain be particularly affected, the nerves of special sense 
may become involved, the most common being an in- 
volvement of the eye, producing strabismus, ptosis, and a 
variation in the size of the pupils. If the seventh nerve be 
affected, facial paralysis appears. Optic neuritis has been 
noted in some cases, and may occur even without pressure 
upon the optic nerve. Hemiplegia and monoplegia are 
common. In children the respiration is quickened, sighing, 
and irregular, Cheyne-Stokes respiration being not uncom- 
mon. Constipation is the rule. Herpes is encountered in 
this form of meningitis. 

Prognosis. — The prognosis is unfavorable. 

Treatment. — Absolute rest and perfect quiet are essential. 
Local blood-letting in robust individuals is useful, especially 
in the early stages of the disease. Ice-bags should be freely 
applied to the head. Laxatives are of benefit, calomel and 
the salines being the most useful. For the hyperpyrexia cold 
baths are indicated. The bromids are of great value. Mer- 
cury and iodid of potassium are highly recommended in the 
treatment, and should be given in full doses. The food should 
be nutritious and consist largely of liquids. If vomiting per- 
sist, rectal alimentation becomes necessary. Administration 
of the perchlorid of iron is to be recommended. 

CHRONIC LEPTOMENINGITIS. 

Etiology and Pathology. — This disease may arise from 
syphilis, from the use of alcohol, and from some of the acute 
varieties of meningitis, which, having run a prolonged course, 
may have become chronic. The lesions consist of thickening 
and gluing together of the membranes. The extent of the 
process is usually circumscribed. 

The symptoms are not distinctive. There may be headache, 
dizziness, and vomiting. At times some of the cranial nerves 
may be involved. 



CEREBRAL HEMORRHAGE. 695 

The treatment consists in the administration of opium, the 
iodids, and mercury, but little is to be hoped for, even from these 
measures. 

CEREBRAL HEMORRHAGE. 

Synonym. — Cerebral apoplexy. 

Etiology. — Heredity is of importance in this affection, the 
apoplectic constitution being present in many individuals. 
Diseases of the blood-vessel walls are the most important 
factors in the etiology, many diseases giving rise to these 
changes. (See Diseases of the Blood-vessels.) It may follow 
some of the infectious fevers, and may also exist in diseases 
producing disturbances of the blood. Embolism is an impor- 
tant factor. Hypertrophy of the heart, exertion, or excitement 
frequently cause rupture of the diseased blood-vessels. It occurs 
at all ages, but is more common after middle life, males being 
more often affected than females in the proportion of four to one. 

Pathology. — The lesions found are atheromatous blood- 
vessels and miliary aneurysms that have ruptured. Disease of 
the blood-vessel walls may arise from an infected embolus 
blocking up the vessel, the wall becoming diseased and an 
aneurysm developing, which subsequently ruptures. The 
lenticulostriated arteries, branches of the middle cerebral, are 
the vessels that most frequently give rise to cerebral hemor- 
rhage. Lesions of other parts of the body, such as chronic 
interstitial nephritis, hypertrophy of the heart, and arterio- 
sclerosis, are often associated with this condition. If the 
hemorrhage be slowly produced, clotting or coagulation fol- 
lows, only a small area being involved ; subsequently the clot 
may undergo softening. The surrounding brain-substance 
may become somewhat discolored, and in some instances a 
yellowish-brown fluid may remain, which is surrounded by the 
cyst-wall ; this is called an apoplectic cyst. Very frequently 
the brain-substance surrounding the area of hemorrhage un- 
dergoes degeneration and softening. If the hemorrhage be 
extensive, marked destruction of the brain tissues will result. 
If the hemorrhage be very minute, absorption takes place in 
some instances, leaving only a small yellow patch. The most 
frequent situation of cerebral hemorrhage is in the corpus stri- 
atum, near the lenticular nucleus, more often involving the left 
than the right side in this situation. The pons Varolii is next 
in frequency in the order of involvement, the white matter of 
the frontal region being next. The optic thalamus may also be 



696 DISEASES OF THE NERVOUS SYSTEM. 

involved. Hemorrhage may take place into the lateral ventri- 
cles ; it is rarely primary. Meningeal hemorrhage or hemor- 
rhage into the arachnoid space is sometimes encountered. 
Extradural hemorrhage is most often of traumatic origin, and 
this is more frequently due to the rupture of the middle 
meningeal artery than to lesions of other vessels. Subdural 
hemorrhage due to rupture of the middle cerebral may also 
arise from tumors, such as sarcomata. Secondary degenera- 
tion of the pyramidal fibers of the medulla and cord ensues if 
the hemorrhage does not terminate fatally. The degenerated 
nerves are finally replaced by fibrous connective tissue. In 
some instances the hemorrhage is so profuse that it may involve 
the whole of the cerebrum. If the hemorrhage be small and 
be absorbed, in some instances a cicatrix remains, which is 
altered by blood-pigments, and is called an apoplectic cicatrix. 
Symptoms. — As a rule, prodromes do not occur ; but when 
present, they consist of vertigo, some mental irritability, 
numbness or tingling in the extremities, and headache. Occa- 
sionally there may be sudden loss of speech. In the majority 
of instances the onset of the attack is sudden, with or without 
loss of consciousness. The suddenness with which the attack 
comes on has given rise to the term " apoplectic stroke" 
(Schlaganfall). There may be sudden sharp pain in the head 
at the onset ; in other cases the beginning of the attack is 
painless. In the majority of instances when the loss of blood 
has been profuse, oncoming coma rapidly follows. It occa- 
sionally happens that the patient partially or completely re- 
covers consciousness, or the unconsciousness from the initial 
attack may become more intense, this condition lasting for 
hours or days before death ensues. This has been called 
ingravescent apoplexy. The skin soon is bathed in perspira- 
tion. The face and neck are turgid and the countenance is 
cyanosed ; on the other hand, in the severest cases there may 
be pallor. The breathing is stertorous. As a consequence 
of fluid in the trachea, loud rales are heard. The cough 
reflexes are diminished, as are also the other reflexes. The 
cheeks are flaccid, and are drawn in and puffed out with each 
respiratory act. The respirations are irregular, deep, and 
slow ; Cheyne-Stokes respiration occurring in fatal cases. 
The pulse varies, commonly it is slow and of good volume ; 
rarely it may be rapid, and an irregular pulse is of unfavor- 
able prognostic import. Vomiting is common early in the 
attack. Often the head is turned to one side, accompanied 



CEREBRAL HEMORRHAGE. 697 

by a conjugate deviation of the eyes in the same direction, 
the patient looking toward the lesion. This symptom is 
not of long duration and disappears after two or three days. 
During a convulsion the deviation may be in an opposite 
direction ; in the case of hemorrhage into the pons the eyes 
look away from the lesion. The pupils may be either 
dilated or contracted ; commonly they are unequal. The 
temperature varies, in individual cases ; in large hemorrhages 
that rapidly prove fatal subnormal temperature is common 
early in the attack ; thus, temperatures of 94 ° F. have been 
recorded. As a rule, reaction occurs after the fall, which may 
be either gradual or rapid. In the milder cases the tempera- 
ture rises to a little above normal, and in the severer cases it 
may reach 108 F. or higher. Commonly there is a differ- 
ence between the two sides of the body as regards temperature. 
The sphincters of the bladder and rectum are relaxed. The 
urine is often copious in amount, and may contain albumin and 
sugar.* One of the most important symptoms of apoplexy is 
hemiplegia. During the deep coma it is often difficult to tell 
which side is paralyzed, but as the coma subsides movements 
are often noticed upon the unaffected side. 

Crossed Hemiplegia. — Crossed hemiplegia may result from 
hemorrhages into the crus, the pons, or the medulla. There 
is a loss of function of one side of the body, and also a loss of 
function in some cranial nerves of the opposite side. 

Symptoms of Hemorrhage into the Crus. — The symptoms 
are paralysis of the oculomotor nerve corresponding to the side 
upon which the hemorrhage occurs, and paralysis of the arm, the 
face, and the leg of the opposite side. If the geniculate body 
which is in relationship to the crus be compressed, hemianopsia 
arises. 

Symptoms of Hemorrhage into the Pons Varolii. — The 
symptoms of hemorrhage in this locality are quite character- 
istic. As a rule, the coma is marked. General convulsions occur, 
which are rarely unilateral ; they may, however, affect only the 
lower extremity. As a rule, the pupils are contracted. The 
temperature falls a degree or so early in the attack, but in a 
very few hours rises rapidly, and hyperpyrexia is noted. With 
involvement of the seventh nerve there is paralysis of the face 
on the side of the lesion, hemiplegia and hemianesthesia occur- 
ring upon the opposite side. When the lesion is high up in 
the pons, the facial paralysis, if it be present, will be upon the 
same side as the hemiplegia. If the sixth nerve be involved, 



698 DISEASES OF THE NERVOUS SYSTEM. 

paralysis of the external rectus occurs, with internal strabismus 
of the eye upon the same side as the lesion. Vomiting, poly- 
uria, albuminuria, and glycosuria are common. 

Symptoms of Hemorrhage into the Medulla. — This is rare. 
If the hemorrhage be profuse, death rapidly takes place. 
The symptoms are similar to those of hemorrhage into the 
pons. 

Symptoms of Hemorrhage into the Cerebellum. — The 
diagnosis of hemorrhage in this locality is very difficult. The 
onset is marked by pain in the occipital region and the back 
of the neck. Vomiting is a constant symptom. Convulsions 
also occur. There is motor paresis of the limbs upon the 
same side as the lesion, and, as a rule, the condition is fatal. 

Symptoms of Ventricular Hemorrhage. — Usually coma is 
profound, and the condition generally terminates fatally. Ven- 
tricular hemorrhage may be suspected if symptoms of cerebral 
hemorrhage have occurred, in which partial recovery has 
taken place, followed by a sudden relapse into deep and pro- 
found coma. The temperature, which may have ascended 
slightly, falls rapidly, subsequent hyperpyrexia again being 
noted. The pupils may be either contracted or dilated. 

Symptoms of Meningeal Hemorrhage. — There is marked 
pain in the head, rapidly followed by coma, with convulsions 
which are often localized early in the attack. Pain and con- 
vulsions are more common in this form of hemorrhage than in 
that of any other part of the brain. 

Duration. — The initial coma may pass off in a few hours, 
the cases in which recovery is likely to occur being of this 
form. A favorable symptom is a return of the reflexes. There 
are, commonly, headache and some slight change in speech, 
which, however, may pass away, nothing but the paralysis 
remaining. Sudden death is quite rare. If recovery ensues, 
the leg is the first to regain power, the arm recovering later. 
The upper portion of the arm and the shoulder recover before 
the hand and forearm. 

Secondary Phenomena. — If the paralysis persist for a long 
time, slight secondary changes develop ; the leg, however, 
frequently regaining some muscular power. Later contrac- 
tures and rigidity develop in the affected membranes, these 
being most pronounced in the arms. There may also be pain.- 
Loss of power necessarily follows these contractures, and 
these changes are associated with sclerosis of the motor paths. 
The reflexes are exaggerated in this stage. Atrophy of the 



THROMBOSIS AND EMBOLISM. 699 

muscles, tremor, arthropathies, and chorea may subsequently 
develop. 

Prognosis. — In favorable cases the coma is rarely profound, 
some return to consciousness being noticed in from two to 
six hours. Cases in which no signs of consciousness are 
apparent after twenty-four hours are exceedingly unfavorable. 
Bradycardia, tachycardia, irregular pulse, slow or rapid respir- 
atory movements, and especially Cheyne-Stokes respiration 
are unfavorable signs, as is also the appearance of sugar and 
albumin in the urine. 

Treatment. — The patient must be placed in bed with the 
head elevated. If the arterial tension be high, venesection 
should be performed immediately. Ice-bags should be applied 
to the head. Croton oil or calomel are of great value in in- 
ducing free purgation. If the patient be unconscious for a 
considerable length of time, the bladder must be evacuated 
with the catheter. 

Treatment of the Subsequent Condition. — The patient is 
necessarily confined to bed for some length of time, therefore 
attention must be given to the skin in order to prevent bed- 
sores. The diet should be light and nutritious. Changing the 
patient's position from time to time is necessary to prevent 
hypostatic congestion. The bowels must be carefully regu- 
lated. Iodid of potassium and tonics are indicated. In some 
instances mercurials are beneficial. If a positive diagnosis of 
meningeal hemorrhage can be made, operative procedure must 
be considered. Massage and electricity are of benefit to the 
paralyzed muscles ; these measures of treatment, however, 
should not be employed early. 

THROMBOSIS AND EMBOLISM. 

Thrombosis. — Thrombosis may develop from lesions of the 
blood-vessel walls, such as atheroma, the small branches being 
frequently the seat of the lesion ; indeed, any roughening of 
the vessel wall may give rise to thrombosis, such as athero- 
matous plates, tubercles, various tumors involving the wall, 
and acute inflammations of the arteries. Thrombosis may 
occur secondarily from an embolus, or in some cases ligation 
of the carotid artery is followed by thrombosis that extends 
upward. In some instances an aneurysm is found to contain 
a large thrombus. 

Changes in the constituents of the blood may give rise to 



700 DISEASES OF THE NERVOUS SYSTEM. 

thrombosis, the following being the most important : In some 
of the primary anemias, particularly chlorosis ; increased fibrin 
in the blood, this being specially noted in pregnancy ; in some 
of the constitutional diseases, as gout, diabetes mellitus, syph- 
ilis ; and in some acute infectious diseases, as diphtheria, en- 
teric fever, and malignant endocarditis. Thrombosis may arise 
from blood parasites. Slowing of the circulation is a cause 
of thrombosis ; it commonly accompanies edema. 

Embolism. — Embolism is most frequently met with in the 
middle cerebral artery upon the left side. This may be due to 
the fact that an embolus finds its way through the left carotid 
artery more easily than through the right, this being the more 
direct course. Emboli most frequently arise from the break- 
ing-up of a vegetation in valvular disease, mitral stenosis being 
the lesion which most commonly gives rise to it, or from a 
clot from an aneurysm, or atheromatous plates in a blood- 
vessel. The breaking-up of a thrombus may give rise to em- 
bolism. Fragments of bones, tumors, and parasites in the 
blood-stream may act as emboli. The affection is more fre- 
quent in females than in males, the greater number of cases 
arising from endocarditis. 

Pathology of Thrombosis and Embolism. — The blocking 
up of a blood-vessel in the brain gives rise to an infarct, 
which may be swollen and anemic ; or the area may be filled 
with blood, called a hemorrhagic infarct. If the embolus be 
infected, an abscess is liable to arise (metastatic abscess). The 
area in which the blood is cut off soon undergoes softening, 
and if much blood be contained in the affected region, it is 
called red softening. Later on, a fatty degeneration ensues 
and the part becomes yellow ; this is known as yellow soften- 
ing, and the latter condition may gradually merge into white 
softening, and the anemic infarct may degenerate and soften, 
constituting the principle of white softening. Inflammatory 
changes often develop around the area of infarction. The 
focus of infarction may gradually be replaced by fibrous con- 
nective tissue, or, in some instances, the degenerated material 
becomes liquefied and a cyst is noted in the area. 

Symptoms of Thrombosis. — Prodromes are common ; 
these consist in drowsiness and headache, the beginning of 
the attack being insidious. Hemiplegia occurs, which is also 
gradual in its onset. Ocular and other cranial nerve palsies 
may occur. 

Symptoms of Embolism. — The symptoms of this closely 



CEREBRAL ANEURYSMS. /OI 

simulate cerebral apoplexy ; indeed, it may be impossible to 
make a differential diagnosis. There is rapid loss of con- 
sciousness, with hemiplegia and disturbances of the pulse and 
respiration. A point of importance would consist in the fact 
that embolism is more frequent upon the left side of the brain 
than hemorrhage ; hence, right-sided hemiplegia with organic 
valvular disease is in favor of embolism. Thrombosis has 
been noted most frequently in the middle cerebral artery, in 
the vertebral artery, in the basilar artery, in the internal 
carotid, and in the anterior cerebral arteries. 

Prognosis. — Recovery from cerebral occlusion is slightly 
more favorable than cerebral hemorrhage. Complete recovery 
from the paralysis is exceedingly rare. 

Treatment. — The treatment is the same as in cerebral 
hemorrhage 

CEREBRAL ANEURYSMS. 

Cerebral aneurysms of fair size occasionally involve the 
larger blood-vessels of the brain, particularly at the base. The 
middle cerebral on the left side is most frequently involved. 
Next in frequency are aneurysms of the basilar artery, the 
internal carotid coming next in order of frequency. 

Etiology. — As in other blood-vessels, arteriosclerosis is 
perhaps the most important causative factor in cerebral 
aneurysms. Other causes may be embolism, trauma, and 
syphilis. Aneurysm is more frequent in the male sex, and 
after middle life. 

Pathology. — The aneurysms van' greatly in size, from a 
miliary character to the size of a hen's egg, or even larger. 
They are commonly sacculated, but the fusiform and cylindric 
varieties have been noted. Rupture of the sac may take 
place, the blood extravasating into the brain-substance, and 
in some instances meningeal hemorrhage is encountered. 

Symptoms. — The symptoms of aneurysm are chiefly those 
of a cerebral tumor. Headache is a constant symptom, and 
is often made worse by straining at stool or .other muscular 
efforts. Vertigo, dizziness, and tinnitus aurium are common 
symptoms. Convulsions and vomiting are occasionally en- 
countered. Rarely apoplectiform attacks take place, which 
may be due to a sudden distention or to a minute rupture. 
Optic neuritis is rare. Occasionally a sensation of pulsation 
that is apparent to the patient is noted, accompanied by sounds 
of which the patient is also aware. Careful auscultation of 



J02 DISEASES OF THE NERVOUS SYSTEM. 

the skull sometimes elicits a distinct bruit. Localization may 
determine the position of the aneurysm. 

Diagnosis is difficult and often impossible. 

Treatment. — The treatment is that of aneurysm in general. 
Internally, iodid of potassium should be given, especially as 
syphilis is so frequently a cause of blood-vessel disease. 

ABSCESS OF THE BRAIN* 

Etiology. — This condition is rarely primary ; it is most 
often secondary to disease of the bones of the skull or soft 
tissues, such as ear disease, nose disease, and so on, to trauma 
of the skull, or to a septic infection carried from some other 
organ, most often the lung. The condition may be acute, 
subacute, or chronic. Abscesses rarely result from some of 
the infectious fevers. It occurs more frequently in males than 
in females, and most commonly between the ages of twenty 
and forty. It is more common in the working classes than in 
the well-to-do, probably because otorrhea is more likely to 
occur, head injury being more frequent among the poorer 
classes. 

Pathology. — The abscess is most often situated in the 
temporosphenoidal lobe, the right side being more often in- 
volved than the left. The cerebellum is less frequently 
involved than the cerebrum, and still more rarely the pons and 
medulla. The reason for this common situation is on account 
of the relation to the internal ear. The abscess formation 
may be solitary or multiple. In the greater number of cases 
it is solitary. The pus may contain various pyogenic micro- 
organisms, and in rare instances the pus has been found 
sterile. The surrounding brain-structures may reveal the 
changes which are noted in acute inflammation, but in some 
instances where the abscess is of long standing, a thick layer 
of fibrous connective tissue is found. In the acute abscesses 
the pus is often blood-tinged, while in chronic abscess it 
is often thin and watery. The size varies greatly ; it may be 
of any size from that of a pinhead to an abscess which in ex- 
treme cases involves nearly the entire brain. 

Symptoms. — The symptoms are variable. Occasionally 
they are very severe, appearing rapidly, while in other cases 
the onset is insidious. The most characteristic symptoms are 
intense headache, vertigo, vomiting, mental dullness, and 
optic neuritis. There is a slow pulse early in the disease. 



ENCEPHALITIS. 703 

The pulse-rate in the greater number of cases is under the 
normal, indeed it is commonly between 40 and 60 a minute, 
and some cases have been noted in which the temperature is 
high and the pulse-rate 40 or 50 a minute. Rare cases have 
been recorded in which the pulse-rate ranged between 10 and 
16 a minute. After surgical interference, in which the pus 
has been evacuated, the pulse-rate increases. Arhythmia is 
very common with this bradycardia. There are drowsiness 
and apathy. There are often gastric disturbances, such as ano- 
rexia, foul breath, heavily coated tongue, and constipation. In 
some instances muscular spasms, epileptiform convulsions, and 
paralysis such as hemiplegia and monoplegia occur. Motor 
and sensory aphasia and hemianopsia are present. Delirium 
is rare, but coma usually precedes the fatal issue. Occasion- 
ally there is marked and rapid wasting. There is much differ- 
ence of opinion as to the range of the temperature. It not 
uncommonly clings to the normal point, and it also happens 
in many cases that it is subnormal. Occasionally some rise 
of temperature is noted — in many cases at the period of onset. 
If the condition be acute in its onset, fever is very often 
present. Some authors have stated that the temperature nearly 
always runs a subnormal course. It is probable that in such 
cases the course of the disease has not been closely observed, 
or that the condition has been attributed to other causes. 
Often at the close of the disease the temperature rises. Rup- 
ture of the abscess into the ventricles or inflammation of the 
meninges gives rise to fever. In the acute and subacute 
varieties fever may occur, but in the greater number of cases 
of this form of brain abscess the temperature is normal 
or subnormal. Respirations are usually slow, from ten to 
fifteen a minute. Cheyne-Stokes respiration occurs in some 
instances. 

Prognosis. — The prognosis is grave. 

Treatment. — The treatment is surgical. Early evacuation 
of the pus is indicated. 



ENCEPHALITIS. 

Inflammation of the brain, either local or diffuse, arises from 
some of the acute infectious diseases ; from intoxications, such 
as food-poisoning, alcohol, nicotin, lead- or gas-poisoning, and 
also from injury. The most important infectious diseases 
giving rise to the condition are influenza, cerebrospinal fever, and 



704 DISEASES OF THE NERVOUS SYSTEM. 

ulcerative endocarditis. It has been known to follow scarlet 
fever, measles, diphtheria, croupous pneumonia, hydrophobia, 
syphilis, pertussis, gonorrheal infection of the brain, tetanus, 
erysipelas, purulent otitis media, and acute anteropoliomyelitis. 

Pathology. — Any portion of the brain may be involved. 
A point of frequent occurrence is in the gray matter : that is, in 
relation to the third and fourth ventricles and the aqueduct 
of Sylvius. 

Symptoms. — As a rule, the disease begins acutely. There 
is either somnolence or coma from the onset, but this may be 
preceded by a stage of irritable jactitations resembling the 
onset of delirium tremens. Headache, vertigo, vomiting, and 
painful contractions of the muscles of the back of the neck are 
common. The pulse-rate is increased, as is also the respi- 
ratory frequency. As a rule, the temperature is normal or 
even subnormal. Rarely, fever is encountered. Incontinence 
of urine occurs in the terminal stages of the disease. Loss of 
appetite and constipation are common. 

Duration. — The duration of the disease is from ten to four- 
teen days. 

Prognosis. — The prognosis is unfavorable, few cases termi- 
nating in recovery. 

Treatment. — Rest in bed is most important. The patient 
is confined to a dark room, and absolute quiet is essential. 
The head should be elevated ; it should be shaved and ice- 
bags applied. Local blood-letting is important. Laxatives 
are extremely necessary : calomel should be given in large 
doses to the point of ptyalism. Iodid of potassium is valuable. 
If pain be severe, opium is indicated. 

HYDROCEPHALUS. 

Definition. — A collection of fluid within the ventricles or 
the subarachnoid spaces of the brain. 

Etiology. — This condition may be either congenital or 
acquired. The acquired variety, sometimes called idiopathic 
hydrocephalus, is due to mechanical disturbances. The cause 
of congenital hydrocephalus is not known. It sometimes pro- 
duces difficult labor. In congenital hydrocephalus the head 
is greatly enlarged and the bones of the skull are thin. The 
fontanels and the sutures may be large and the bones widely 
separated. Fluctuation may be detected. The face frequently 
appears small in comparison to the great enlargement of the 



TUMORS OF THE BRAIX. 705 

cranium. Upon examination of the brain in this condition it 
will be found that the ventricles are distended with fluid, 
which is usually clear. The brain-substance is flattened, and 
there is also fluid in the subarachnoid spaces. 

Symptoms. — The symptoms of congenital hydrocephalus 
are difficulty in movements of the child on account of the 
weight of the head. There is impairment of intellect, but in 
some instances the mental capacity is good. 

Acquired hydrocephalus may arise from a tumor at the base 
of the brain, giving rise to engorgement of the ventricular 
plexus of veins. 

The symptoms vary. There may be headache and dimness 
of vision and the gait may become irregular. The pulse is 
usually slow. Many cases are difficult to diagnosticate. 

Treatment. — Treatment is usually of no avail in this con- 
dition. Operative methods are advised by some authorities. 



TUMORS OF THE BRAIN. 

The following tumors have been found in the brain : 

Glioma. — This tumor is limited to the central nervous sys- 
tem and the retina. It is usually solitary and quite firm, but 
in some instances it is soft and vesicular. These tumors may 
undergo softening and fatty degeneration, and a cyst may 
replace a great part of the new growth. The fluid is clear or 
turbid, and in some instances is black. These tumors vary 
greatly in size — from the size of a pea to that of a man's fist. 
The tumor may also undergo myxomatous degeneration, and 
is then known as gliomyxoma. 

Neuroma may be found sometimes combined with glioma, 
when it is known as neuroglioma. 

Sarcoma is quite common in the membranes, also arising 
from the bones of the skull, and in the adult this is a com- 
mon form of brain-tumor. It may also be found in the 
pons. Many varieties of sarcomata have been encountered. 
Fibromata and osteomata are very rarely found in the brain. 
Adenomata and lipomata have been noted. Carcinomata may 
be either primary or secondary ; in the greater number of 
cases they are secondary. Psammomata and cholesteatomata 
have been found. Gummata are commonly encountered in 
the brain. 

Cysts of the Brain. — Cysts may develop from brain soften- 
45 



706 DISEASES OF THE NERVOUS SYSTEM. 

ing. Hydatids and cysticercus cellulosae have been known to 
occur in the brain. 

Symptoms. — As a rule, the symptoms of an intracranial 
growth are quite characteristic, but it must be stated that they 
may exist without giving rise to symptoms intra vitam. Gen- 
erally, the characteristic symptoms consist in headache, optic 
atrophy, sensory disturbances, convulsions, vomiting, vertigo, 
and bradycardia. 

Headache. — This is an almost constant symptom of cere- 
bral tumor. It varies in severity, but, as a rule, is pronounced, 
increasing in intensity as the disease advances. It may be so 
severe that loss of consciousness due to the pain ensues. The 
pain is often described as diffuse, occupying the entire skull, 
or it may be deep-seated. It is often unilateral and localized to 
the temporal region. Pain which is constant in a local area in 
the head is always suggestive of an intracranial growth. The 
pain is increased by muscular movement, the use of alcohol, 
sneezing, excitement, change of posture, and so on. If pain 
be marked in the anterior portion of the head, it may extend 
down the face ; and if it be felt in the back of the head, it 
sometimes radiates down the neck. 

Optic Neuritis. — Double optic neuritis is very frequent in 
tumor of the brain ; indeed, it is probably a symptom of more 
diagnostic value than headache. It may not be associated 
with a decrease in the field of vision, the latter often being 
normal. Single optic neuritis is less frequently encountered 
than double. When the neuritis is more pronounced on one 
side, it points to the fact that the growth is probably situated 
on the side showing the most marked inflammation of the 
optic nerve. 

Disturbances of the Sensorium. — The patient is easily tired, 
any exertions readily fatiguing him. Numbness is complained 
of, especially in the skull, and it is difficult for the patient to 
express his ideas. He has a sleepy, tired expression ; he 
answers slowly, questions having to be repeated several times 
before an answer is elicited. Finally, stupor and coma 
occur. The sphincters are relaxed. Melancholia is noted, 
and in rare instances talkativeness is encountered. Localized 
convulsive seizures occur, especially in cases in which the 
growth irritates and involves the cortex. The spasms may be 
confined to single muscle-groups, but may gradually extend 
and become general. Occasionally apoplectiform attacks are 
encountered. The status epilepticus is not infrequent. Vom- 



TUMORS OF THE BRAIN. JOJ 

iting takes place, especially when the base of the brain or the 
pons and the medulla are involved. As a rule, it is an early 
symptom, and is cerebral in character. It often occurs early 
in the morning, upon awakening, and may also occur with 
change of posture, without much nausea and retching, often 
with a clean tongue, and without influencing the appetite. It 
may be the precursor of an epileptiform attack. 

Vertigo. — Vertigo may be present, most often as a tempo- 
rary condition, and is due to disturbance of the cerebral circu- 
lation. If the vertigo be constant and severe, it is likely that 
the tumor involves the cerebellum. 

Bradycardia. — In a limited number of cases the pulse 
may be slowed only for a brief time ; bradycardia is, however, 
not so constant as a symptom of intracranial growth as it is 
in cerebral abscess. In some rare cases tachycardia has been 
noted. 

Temperature. — As a rule, the temperature is normal or 
subnormal, fever being due to complications, particularly 
cerebritis and meningitis. If the tumor be situated in the 
basal ganglia, pons, or medulla, there may be hyperpyrexia. 
In some cases dyspnea is noted, as is also Cheyne-Stokes 
respiration. Yawning and hiccup (singultus) occur. Inco- 
ordination is rare ; it is present when the growth involves the 
cerebellum. 

Localizing Symptoms. — The Motor Centers. — If the tumor 
produce irritation of the lower portion of the motor area, spasm 
of the face or tongue is noted. Involvement of the middle 
portion will produce spasm of the arm, hand, or shoulder ; 
and if the lesion be in the upper portion, similar symptoms 
develop in the leg, thigh, toes, and ankles. In some instances 
there are numbness and tingling, which are appreciated by the 
patient before the spasm begins. If portions of the motor 
area be destroyed, paralysis results in the muscle-groups that 
are in relation to those particular motor centers. Motor 
aphasia is produced by tumors involving Broca's convolution. 
The point of origin or signal symptom should be determined 
if possible, also the condition of the affected portion, — whether 
there be anesthesia or paralysis, — and also the character of 
the spasm. 

Prefro7ital Region. — In this region motor or sensory distur- 
bances are often noted. Exophthalmos upon the affected side 
is observed in some cases. 

Parieto-occipital Lobe. — Mind-blindness and word-blindness 



708 DISEASES OF THE NERVOUS SYSTEM. 

are produced. The angular gyrus and the white matter be- 
neath in some instances do not produce any symptoms. 

Occipital Lobe. — Blindness, hemianopsia, and sometimes 
word-blindness and mind-blindness are noted when this lobe is 
involved. 

Temporal Lobe. — If the lesion involves two-thirds of the 
posterior part of the first temporal convolution, and perhaps 
the second be involved, there is word-deafness, but sometimes 
a large tumor may exist in this area without giving rise to 
symptoms. 

The Basal Ganglia. — Tumors situated in this area may pro- 
duce hemianopsia, hemianesthesia, and in some instances 
hemiplegia. Optic neuritis and disturbances of the cutaneous 
and muscular ganglia are also noted. When the tumor in- 
volves the crura cerebri, ocular symptoms are pronounced, 
such as nystagmus and absence of pupil reflexes. There is 
ocular motor paralysis on one side when the third nerve is in- 
volved, and often hemiplegia of the opposite side. 

Pons and Medulla. — The Pons. — Alternate paralysis may 
occur ; that is, hemiplegia on one side, and the nerves involved 
on the opposite side. If the lesion be in the lower and inner 
portion of the crus, there will be paralysis of the third nerve and 
of the limbs, face, and tongue of the opposite side, known as 
the syndrome of Weber. If the sixth nerve be involved, there 
will be internal strabismus. If the seventh nerve be affected, 
there will be facial paralysis. Deafness follows lesions of the 
auditory nerve. 

Medulla. — If the medulla be involved, paralysis of the nerves 
and hemiplegia may result. Tumors in this region also fre- 
quently produce vomiting, respiratory and cardiac disturbances, 
sometimes retraction of the head and neck, and difficulty in 
swallowing. If the cerebrum be involved, there may be 
symptoms of disturbed incoordination. 

Prognosis. — The prognosis is always serious, with the 
exception of growths due to syphilis, when treated early. 
Surgical interference is sometimes beneficial in other varieties 
of tumors. 

Treatment. — The patient must be placed in bed, and if 
possible absolute quiet maintained. The diet should be light 
and nutritious. The bowels must be carefully regulated, and 
full doses of iodids be given. If iodids do not relieve, mer- 
curials should be tried ; and if these measures do not afford 
relief, a surgeon should be consulted. If the tumor be local- 



CEREBRAL PALSIES OF CHILDREN. 709 

ized, surgical interference is often possible. Opium in some 
form is indicated to relieve the pain. 



CEREBRAL PALSIES OF CHILDREN* 

Two varieties of this affection have been observed — that 
which is noted at birth being called birth palsy, and one which 
occurs some time after birth, being preceded by health, and 
called infantile hemiplegia. The former usually involves both 
legs or both arms, while the latter is usually hemiplegic. 

BIRTH PALSY. 

Etiology. — This disease may arise from abnormalities of 
labor or may have its origin during intra-uterine life. It is 
due either to disease of the mother or to abnormalities of the 
fetus when occurring in intra-uterine life. 

Difficult labor is an important cause, or, in some cases, a 
precipitate labor. Commonly, it arises in those instances in 
which forceps are employed. Young primiparae are not so 
liable to give birth to children suffering from this affection 
as older primiparae. Birth palsies are more frequent in males 
than in females. Syphilis seems to play a part in the pro- 
duction of this disease. 

Pathology. — A lesion commonly present is hemorrhage 
in the membranes, giving rise to pressure upon various brain- 
centers. If there be pressure upon the third frontal convo- 
lution, disturbances of speech are noted, and if the lesion 
extend forward, there may be disturbances of the muscles of 
the eye ; hence, squint may be encountered. If the disease 
has persisted for some time, the brain is frequently found 
softened (porencephalus) or there may be sclerotic changes. 

Symptoms. — The symptoms are those of weakness asso- 
ciated with stiffness, which may involve both legs or both 
arms, sometimes both legs and one arm, and occasionally one 
arm and one leg on the same side. The gait is spastic if the 
legs be involved, the patient dragging the affected member. In 
some instances ankle clonus is present. The knee-jerks are 
exaggerated. Walking may be entirely interfered with, and 
spasm may develop. A tremor may be present. The ocular 
muscles are sometimes paralyzed, either singly or in groups. 
In some children the mental condition is very much dis- 



7IO DISEASES OF THE NERVOUS SYSTEM. 

turbed, while in others it is good ; indeed, in some instances it 
may be acute. Speech may be disturbed. Convulsions which 
have a tendency to recur are noted.. Such deformities as 
talipes and curvature of the spine often develop as the child 
grows older. 

Prognosis. — The prognosis is unfavorable, although it 
must be said that some cases improve. The usefulness of 
the arms and legs is often much impaired, and if there be 
mental disturbance, there is little hope for improvement. 

Treatment. — Careful hygienic measures are important. As 
the child grows older systematic exercise and massage are 
useful. Tonic treatment is quite important. The food should 
be nutritious and easily digestible. If possible, deformities 
should be prevented. 

INFANTILE HEMIPLEGIA. 

Etiology. — This occurs before" the sixth year, most fre- 
quently during the first two years of life. 

Pathology. — There is still much discussion as to the lesion. 
Two views are held — one by Striimpell, who believes that the 
affection is the result of an acute inflammatory condition of 
the gray matter of the cortex ; and, second, there is a view 
held by Gowers, who believes that it is due to vascular ob- 
struction. 

Symptoms. — The onset is frequently marked by general 
malaise and slight fever, which terminates in a convulsion, 
the fit beginning upon the side which is afterward para- 
lyzed. Convulsions recur at short intervals. The tongue 
is often bitten, the sphincters are relaxed, and consciousness 
is lost during the fit. Rarely there is no convulsion and 
only momentary loss of consciousness. The paralysis, as 
a rule, involves the face, arm, and leg, and is most marked 
in the arm, while the face suffers but slightly. As the 
child grows, the parts fail to develop ; this hypoplasia being 
a striking feature of the disease. The knee-jerk is increased, 
and ankle clonus may be present. In some instances there 
is a peculiar tremor (chorea spastica), which is produced 
during voluntary movements. Mental weakness may follow 
the condition. 

Prognosis. — The prognosis is good as regards life. Men- 
tal impairment and physical debility persist, but occasionally 
improvement is noticed in the affected paralyzed members. Im- 
pairment of speech rarely persists. 



EPILEPSY. 7 I I 

Treatment. — Hygienic measures are of the greatest im- 
portance in the treatment. Systematic exercise and massage 
are indicated. During the convulsions inhalations of small 
quantities of chloroform are frequently effective. After the 
attack a course of bromids is useful. 



GENERAL AND FUNCTIONAL DISEASES OF 
THE NERVOUS SYSTEM. 

EPILEPSY. 

Definition. — Epilepsy is a disease of the nervous system, 
characterized by loss of consciousness, with or without con- 
vulsions. It is a common disease, and it is estimated that 
I in 500 persons suffers from it. 

Synonym. — Falling sickness. 

Etiology. — Heredity plays an important part in the pro- 
duction of this disease. Gowers, in an analysis of 1450 
cases of epilepsy, found a family history of the disease in 
two-thirds, and a previous history of insanity in one-third 
of the cases. In neurotic families the females are more 
likely to suffer than the males. Alcoholism and syphilis 
are important predisposing causes, in as far as heredity is 
concerned. The majority of cases begin before the twentieth 
year of life. Injury to the head may produce epilepsy, as do 
organic lesions of the brain-substance, such as thrombosis or 
embolism. It may follow the infectious diseases, especially 
scarlet fever, cerebrospinal fever, measles, and enteric fever. 
It sometimes follows the prolonged use of some drugs, as 
alcohol, lead, antipyrin, and cocain. The retention of putre- 
factive products in the gastro-intestinal tract, giving rise to 
auto-intoxication, may cause epilepsy. Sunstroke, sexual 
excesses, menstrual irregularities, and masturbation have been 
noted as causative factors. Occasionally, epilepsy is said to 
be due to reflex causes, such as intestinal worms, old cica- 
trices, nasopharyngeal disease, and eye and ear affections. 
Mental emotion and anxiety must also be mentioned as ex- 
citing attacks in those who are affected with the disease. 

Symptoms. — The symptoms vary ; they first begin with 
premonitory signs, so that the patient may be able to tell that 



712 DISEASES OF THE NERVOUS SYSTEM. 

an attack is coming on. These premonitory symptoms are 
known as the anrcz. The aurae may consist of a feeling of 
uneasiness, with restlessness, irritability, and anxiousness. 
There may be fear or emotion, the patient having queer ideas, 
and a feeling that something is going wrong. Sometimes 
insanity may precede the attack (preepileptic insanity). On 
the other hand, flashes of light may occur and a certain 
color may appear before the eyes, or there may be actual 
loss of sight. Visions may appear, which may be either 
pleasant or disagreeable. Loss of hearing is not uncommon, 
or there may be peculiar sounds, such as hissing, whistling, 
or musical. Occasionally disagreeable odors occur, or there 
may be a peculiar taste in the mouth — salty, bitter, sour, or 
sweet. There may be a sensation of numbness and tingling 
in the extremities, which usually rises toward the head ; 
sometimes this sensation begins in the thumb, fingers, wrist, 
or foot, and travels upward. In other cases there is dis- 
comfort in the epigastric region, this even amounting to 
severe pain, which progresses toward the head. When it 
reaches the throat, there is a sensation as if there were 
a ball situated there. This may be associated with nausea, 
vertigo, and headache. Occasionally muscular movements, 
twitchings, etc., take place. There may be paralysis, and, 
finally, there are sensations of chilliness or heat, and con- 
gestion or sweating of the extremities. In many instances 
the aura is absent altogether. 

The Attack. — The attacks are divided into two principal 
classes — the severe or major epilepsy {grand vial), and the 
light or minor attacks (petit ma/). 

Major Epilepsy. — The attack often begins with a loud cry 
(the epileptic cry), the patient falling into unconsciousness, and 
into a state of tonic spasm. The face often becomes cyan- 
otic, the head may be thrown backward or rotated to one side, 
the spine is often curved backward, and the legs are extended. 
The phalanges are often flexed and the thumbs drawn into the 
palms. The jaw is locked and the spasm may be so powerful 
as to dislocate certain joints. Soon twitchings take place in the 
muscles of the face, neck, and extremities. The tongue may 
protrude between the teeth and is often bitten. The pulse- 
rate is quickened, the respiration is rapid, the pupils are dilated 
and do not react to light. If the convulsions are long con- 
tinued, the temperature may rise to 105 ° F. or over ; otherwise 
the temperature remains normal. The body is covered with 



EPILEPSY. 713 

cold sweat, and involuntary evacuation of urine and feces is 
common. The symptoms gradually ameliorate, the patient 
recovers consciousness or falls into a deep sleep, which may 
last from several minutes to several hours. 

Minor Epilepsy. — There may also be many variations in this 
form of epilepsy. It is characterized by momentary loss of 
consciousness without convulsions. Occasionally there may 
be slight twitching of the muscles. Rarely the patient falls to 
the floor, but recovers immediately. The attack is brief, the 
patient recovering almost momentarily. Pallor of the face 
and involuntary evacuation of urine sometimes occur. Both 
forms, major and minor epilepsy, are sometimes replaced by 
conditions of unusual excitement or depression, which is called 
psychic epilepsy. This may last for an hour or more, in 
which the patient may develop homicidal tendencies. In 
some cases a prolonged sleep may take the place of the 
psychic equivalent. 

Postepileptic Symptoms. — As a rule, there is more or less 
headache, but the attack may terminate without further symp- 
toms. After a severe paroxysm the reflexes are usually 
diminished or absent. Later this follows a period of excite- 
ment, in which the knee-jerks are exaggerated and ankle 
clonus occurs. In the majority of cases the patient goes into a 
prolonged sleep. Rarely great hunger develops after an 
attack. Occasionally insanity may result. The patient may 
have but one seizure a year, or one a month, or he may have 
several in a day. Occasionally attacks of epilepsy follow each 
other so rapidly that there appears to be no interval of rest. 
This is known as the status epilepticus. When this occurs, 
death is not uncommon. Occasionally the entire attack takes 
place at night, while the patient is sleeping. This has been 
termed nocturnal epilepsy. 

Course. — The disease is extremely chronic, and the ten- 
dency is to an increase rather than to a decrease of the 
attacks. Insanity develops in \O°/ of the cases, and some 
mental impairment occurs in many well-marked cases. It may 
be stated in general terms that the average length of life is 
shortened by epilepsy. 

Diagnosis. — In a well-marked case the diagnosis is easy ; 
it is only in ill-defined cases that difficulty arises. 

A differential diagnosis must be made between epilepsy, 
syncope, and hysteric attacks. 



7H 



DISEASES OF THE NERVOUS SYSTEM. 



Epileptic Seizures.* 
Absence of exciting causes. 

Aura of brief duration or absent. 

Sudden loss of consciousness. 
Pulse normal. 

Pupils dilated and light reflex lost. 
Spasm tonic and clonic. 
Often involuntary micturition and defe- 
cation. 
Biting of the tongue. 
Cyanosis. 

Short duration of unconsciousness. 
Automatism or stupor after attack. 



Fainting Attacks. 
Exciting causes in the way of hot rooms, 

bad air, emotional strains. 
Premonitions for some time before loss 

of consciousness. 
Gradual loss of consciousness. 
Pulse weak, often scarcely perceptible. 
Pupils small or unchanged. 
No spasm. 
Rarely or never. 

No biting of the tongue. 

Pallor. 

Duration of unconsciousness longer. 

Speedy recovery after attack. 



Epileptic Seizures.* 
No exciting cause. 
Aura or no premonition. 
Epileptic cry. 

Sudden and complete loss of conscious- 
ness. 
Pupils dilated. 
Tonic followed by clonic spasm. 

Biting of the tongue. 

Involuntary micturition and defecation. 
Duration brief. 



Hysteroid Attacks. 
Emotional cause. 
Globus, palpitation, malaise. 
Crying, talking, screaming during attack. 
Loss of consciousness incomplete. 

Pupils unaltered. 

Rigidity, opisthotonos, struggling and 

tossing movements. 
Biting at self or others and objects at 

hand. 
Never. 
Duration often for long periods. 



Prognosis. — The prognosis as to cure is unfavorable. 
Under the most favorable circumstances it has been estimated 
that only from 2 c / to 6 <fo recover. The treatment may re- 
lieve the patient and hold off the paroxysms for some time. 
The more favorable cases for cure are in those of epilepsy 



arising in adult 



life. 



Treatment. — The physician should endeavor to determine 
the cause of the illness, which should be removed if possible. 
It is best for the epileptic to be treated in an epileptic colony 
in which he may have out-door occupation. The general 
health must be carefully looked after. The bowels should be 
kept open and the diet regulated. The diet should consist 
of meat, fruit, cereals, and vegetables, meat being sparingly 
partaken of and only once a day. Cold sponge-baths (60 ° F. 
to 70 ° F.), twice daily, are of decided benefit. The medicinal 
treatment is chiefly empirical, the best results having been ob- 
tained by the use of the bromids. A combination of some one 
of the bromids with antipyrin is favored by some practitioners. 
Surgical interference as a cure for epilepsy, such as excision of 



From Loomis-Thompson. 



INFANTILE CONVULSIONS. 7 I 5 

a cortical focus, or opening of the membranes, has not proved 
successful. 

JACKSONIAN EPILEPSY. 

Definition. — A disease of the nervous system characterized 
by convulsions, and due to some irritative lesion of the cortical 
motor centers of the brain. 

Synonym. — Cortical epilepsy. 

The affection is due to an irritative lesion of the cortex of 
the brain which may destroy the region in which it is situated. 
The irritation may be due to an exostosis, a depressed fracture, 
tubercular and other tumors, meningitis, and especially syph- 
ilitic disease of the cortex. 

The lesion tends to destroy the affected area, giving rise 
to paralysis w r ith secondary degeneration. If this affect par- 
ticularly the face, arm, or leg, the position of the lesion can 
be determined with more or less accuracy., 

The symptoms consist of spasm, which, as a rule, is local 
in character. It is always so at the commencement of the 
affection, but as the disease advances and spreads the spasm 
(convulsion) may become general. As a rule, and especially 
in the milder forms, consciousness is preserved. Sometimes 
tingling and other sensory phenomena may precede the at- 
tack. 

The treatment is surgical. 

INFANTILE CONVULSIONS. 

Synonym. — Eclampsia. 

Convulsive attacks similar to those of epilepsy are not in- 
frequent in children. The attacks differ, however, in the 
fact that when the cause is removed, there is no return. 

Etiology. — Gastro-intestinal disturbances, such as entero- 
colitis, which give rise to debility cause convulsions in chil- 
dren. Irritations due to dentition, overloading the stomach, 
intestinal parasites, otitis, and phimosis produce the disease. 
In the course of rickets convulsions are not uncommon. 
The acute infectious diseases often begin in children with 
convulsions, particularly croupous pneumonia, scarlet fever, 
and measles. Congestion of the brain occurs during the 
course of whooping-cough, and may produce the condition ; 
and diseases of the nervous system, such as infantile hemi- 
plegia, meningitis, tumors, and other brain lesions, cause the 



yi6 DISEASES OF THE NERVOUS SYSTEM. 

affection. Occasionally convulsions occur at birth, and may 
persist for weeks or months. 

Symptoms. — The attack comes on suddenly, occasionally 
being preceded by restlessness, grinding of the teeth, or 
muscular twitchings. The spasm may begin in the hand, 
most often in the right hand. The eyes stare and are fixed, 
the body becoming stiff, and the respiration may be sus- 
pended, causing congestion. Clonic spasms commonly follow. 
When the attack subsides, it is often followed by sleep or the 
child may become stupid and pass into coma. As a rule, 
when the attacks are due to indigestion, the convulsion is 
single. In rickets and intestinal disorders several convulsive 
seizures may follow one another. If the attack is limited to 
one side, there may be slight paresis ; but if the attack be due 
to infantile hemiplegia, complete paralysis follows. During 
the attack the temperature is raised. 

Prognosis. — When the convulsion follows intestinal dis- 
ease, the prognosis is- unfavorable. Convulsions occurring in 
the acute infectious diseases and those resulting from intes- 
tinal and peripheral irritation are not so severe, recovery often 
taking place. 

Treatment. — The cause of the convulsion should, if pos- 
sible, be removed. If it be due to an overloaded bowel, an 
emetic or a purge should be promptly given. If it is the 
result of undigested food, an emetic may often be employed. 
If the child be teething and the gum looks abnormal, 
it should be lanced. During the convulsion the child 
should be placed in a warm bath (about 95 ° F.), and cold 
compresses or cold water applied to the head. During the 
attack chloroform may be given by inhalation. If the con- 
vulsions occur after the child comes out of the chloroform 
narcosis, opium should be given with great caution. Amyl 
nitrite may be used by inhalation or chloral may be given 
by the bowel. After the attack a course of bromids is use- 
ful. Every effort should be made to preserve the nutrition of 
the child. 

CHOREA. 

Definition. — Chorea is a disease of the nervous system,, 
characterized by involuntary contractions of muscles or mus- 
cle groups, accompanied by weakness and often by slight 
mental derangements. 



CHOREA. 717 

Synonyms. — Chorea minor ; Sydenham's chorea ; St. 
Vitus' dance. 

Etiology. — Chorea is a disease of childhood, although it 
may occur at any age. Between the fifth and the fifteenth years 
is the age at which the affection most commonly develops. 
Females are more apt to be affected than males, and it is very 
likely to occur in children who are descendants of neurotic 
parents. The disease is more common in temperate climates, 
and it affects particularly the white race, the negro and the 
Indian having some degree of resistance. It is most prevalent 
in the spring months. Acute rheumatic fever has been noted 
as an exciting cause in over 20^ of the cases. School life, 
fright, shock, worry, and strain have been noted as predis- 
posing factors. It occasionally results from reflex causes, such 
as intestinal worms, eye-strain, nasal disease, and sexual 
disorders. 

Pathology. — The pathology of chorea is still very obscure, 
and no constant lesions are encountered. By some it is be- 
lieved to be a functional brain disturbance affecting the centers 
which control the motor apparatus, while others believe that it 
is due to embolism, as emboli have been found in some of the 
smaller vessels of the brain. Some observers hold the view 
that it is an infection, as it is so frequently associated with 
acute rheumatic fever and endocarditis. 

Symptoms. — The disease begins with feeble involuntary 
twitchings of the muscles of the face or hands. In the beginning 
the affection is most often unilateral. Twitchings of the mouth, 
jerking of the head, and winking are all common. Some loss 
of power is found in the hand, as the patient drops articles 
when the involuntary spasm comes on. The patient can not 
sit still ; the shoulders are twisted ; walking is sometimes 
rendered difficult, and the patient is apt to stumble. Soon 
both sides of the body become implicated, and the involun- 
tary movements increase, but they are usually marked upon 
the side first affected. There may be twitching of the tongue 
and lips, speech becoming affected, and deglutition may be 
interfered with. As a rule, the movements cease in sleep, but 
in severe cases the muscular contractions may continue during 
sleep and interfere with the patient's rest. The child becomes 
restless, irritable, and peevish. There is emotional disturbance 
and sometimes dullness. The appetite is interfered with, and 
some anemia and loss of flesh are noted. Occasionally 
nocturnal enuresis occurs. The specific gravity of the urine 



7l8 DISEASES OF THE NERVOUS SYSTEM. 

is high, there being an excess of urea and phosphates. There 
are no reactions of degeneration. The pulse is frequent — from 
ioo to 130 a minute, even without a cardiac lesion. In 
some cases there is a blowing murmur heard over the heart, 
which may be either functional or organic. In from two to 
five weeks the acme of the disease is reached. As a rule, 
it continues for several months or longer. In rare instances 
the affection may be limited to- one side ; it is then known as 
liemiclwrea. In other cases the twitchings may be slight, 
but the motor symptoms very marked ; this condition is rare, 
and has been termed paralytic chorea. 

Prognosis. — The disease is rarely fatal except in those 
cases in which great mental excitement occurs with delirium, 
hallucinations, and illusions. This has been called dwrea in- 
saniens or maniacal cliorea. Relapses are common, the average 
number being two. 

Treatment. — If the child attends school, it had better be 
taken away and its studies discontinued. Rest in bed with long 
sleeping hours is of marked benefit. In the severer cases the 
child must be kept constantly in bed ; in other cases mod- 
erate exercise in the open air is of use. Sponging with cold 
water, especially the back, chest, and neck, is of great benefit. 
The diet should be simple — meats and highly seasoned foods 
being excluded. Arsenic, antipyrin, bromid of zinc, and quinin 
are the most useful drugs. 

CHOREIFORM AFFECTIONS. 

THE SPASMODIC TICS, 

Various forms of spasm have been described resembling 
chorea. These are chronic in nature, the spasm often being 
violent, the disease lasting for many months or years. The 
following forms have been described : (1) Habit-spasm or 
habit-chorea ; (2) spasmodic tic, including wry-neck and 
mimic spasm ; (3) psychic tic. 

Etiology. — The disease almost always occurs in childhood, 
between the fifth and the fifteenth years. Males are more fre- 
quently affected than females, the child most often being of a 
neurotic temperament. The disease may follow an attack of 
ordinary chorea. Occasionally overwork, fright, injury, or 
shock may act as predisposing causes. Masturbation is also 
an etiologic factor. 

Symptoms of Habit=spasm. — These consist of an irregu- 



CHOREIFORM AFFECTIONS. 719 

lar twitching of the facial muscles, particularly those of the 
mouth and eyes. A constant snuffling of the nose is also 
common. The muscles of the shoulders often jerk, as may 
also those of the arms and legs. 

Spasmodic Tic Proper. — As soon as the spasm becomes 
localized, one or several nerve-centers becoming involved, it 
is known as spasmodic tic. Of this there are many clinical 
varieties. A common type is where the muscles of the larynx 
are affected. This is known as laryngeal tic, or chorea of the 
larynx. At intervals the patient may whistle, bark like a dog, 
or the cry may resemble the epileptic cry, and there may be 
cough and frequently repeated hacking. The spasms are 
increased under excitement, and they disappear during sleep. 
The muscles of the trunk may be affected so that the gait 
becomes awkward. 

Wry-neck. — In some cases there is a tonic spasm of the 
sternocleidomastoid and trapezius muscles. 

Facial Tic. — Tic douloureux is occasionally associated with 
spasm of the muscles of the face, known as facial tic. It is 
most common in advanced life, occurring particularly in 
women. 

Jumping Disease (Myospasmia ; Gilles dc la Tourcttc' s Dis- 
ease). — This is a curious form of convulsive spasm in which 
involuntary explosive utterances, which are frequently pro- 
fane, occur. It has shown itself in many countries. The 
disease begins in the child between the ages of five and six- 
teen years, and is more prevalent in the male than in the female 
sex. The disease occurs in neurotic families, often being 
hereditary. In this country those affected with the disease are 
often called the "jumpers." 

Prognosis. — The prognosis is good, as a rule. The 
spasmodic tics occurring in the muscles of the neck, face, 
and trunk are not so favorable, and the psychic tics gen- 
erally are incurable. 

Treatment. — The treatment consists of the same thera- 
peutic measures that are carried out in chorea proper. 

HEREDITARY CHOREA, OR HUNTINGDON'S CHOREA. 

This is a very rare disease. It is always hereditary and 
most frequently by direct transmission. The disease is trans- 
mitted through the sexes equally. Both sexes are equally 
affected. Xo exciting cause has been discovered. 

The symptoms consist in slight jerking movements of the 



720 DISEASES OF THE NERVOUS SYSTEM. 

facial muscles or of the muscles of the extremities. The 
patient makes curious gestures, the gait is interfered with, 
the muscles of the face being particularly affected. With all this 
there is marked interference with the mental processes. At 
first loss of memory is slight, but later it becomes so marked 
that the patient can not attend to his ordinary occupations. 
Periods of excitement occur, rarely, however, with active 
mania or with homicidal or suicidal tendencies ; occasionally 
acute mental symptoms develop. Melancholia is a promi- 
nent symptom. So few cases have been reported that the 
opportunities for postmortem studies have been necessarily 
limited. The process appears to affect primarily certain 
groups of nerve-cells with degenerative changes and menin- 
geal thickening. 

Prognosis. — The disease is fatal, although the course may 
be prolonged. 

Treatment. — The treatment is purely symptomatic and 
prophylactic. Choreic individuals should not be permitted 
to marry or intermarry. No drugs have been described that 
have any especial effect. 

MIGRAINE. 

Synonym. — Hemicrania. 

Etiology. — Women suffer to a greater extent than men in 
the proportion of three to one. The disease often begins in 
childhood, and is rare after fifty ; it shows strong hereditary 
tendencies. Digestive disturbances are frequently associated, 
and the disease occurs in neurotic females. - 

Symptoms. — The principal symptom is the headache, 
which shows more or less periodicity, the patient in the in- 
terval often enjoying perfect health. At the onset there 
are often prodromes, such as a feeling of uneasiness or lan- 
guor. These symptoms are followed by pallor and some 
vasomotor spasm. As the headache becomes severe, flushing 
of the face succeeds the pallor. The disease is, as a rule, 
unilateral, the left side being oftener affected than the right ; 
both sides of the head may be affected. The pupil upon 
the affected side is often smaller, and the eye may be re- 
tracted. Often permanent local grayness of the hair is 
noted upon the affected side. There is commonly disturb-" 
ance of vision, the duration, however, being temporary. There 
are flashes of light, blurring of the sight, hemiopia, and pho- 



PARALYSIS AGITAXS. 721 

tophobia. Occasionally there is tinnitus aurium associated 
with vertigo. In the majority of cases the symptoms are 
accompanied by marked gastric disturbances, such as nausea, 
with frequent vomiting. The retching often becomes extreme 
and aggravates the headache. The urine passed during the 
attack is high colored, being rich in solids. 

Prognosis. — The prognosis is favorable, although the at- 
tacks recur and may become more frequent. 

Treatment. — The treatment consists in the management 
of the attack and the prevention of the recurrence. Many 
drugs have been advised for the relief of the pain. Ergot in 
full doses has been recommended. Some of the coal-tar 
products, such as antipyrin, antifebrin, and phenacetin, are of 
use, especially if administered early. The use of full doses of 
salicylate of sodium is valuable in some cases, while in other 
instances the bromids, with caffein, are of benefit. Gelsemium 
has also been highly recommended. Underlying conditions, 
such as lithemia, the gouty 'diathesis, digestive disturbances, 
and constipation, should be looked after. As a prophylactic, 
nitroglycerin in y^-grain doses, taken after meals, with 
bismuth and pepsin, has been said to be of value. Mild purg- 
ing with calomel from time to time often prevents attacks. 

PARALYSIS AGITANS. 

Synonyms. — Parkinson's disease ; shaking palsy. 

Etiology. — The disease is one of advanced life, beginning, 
as a rule, between the ages of forty and sixty. Men are 
twice as often affected as women. The influence of heredity 
has not been definitely determined. Great stress has been 
laid upon fright, mental emotion, trauma, and illness as etio- 
logic factors. It does not appear that alcohol, tobacco, and 
lead are causative factors. 

Pathology. — The pathology of this disease is still obscure. 
Some believe the affection to be a functional disorder, while 
others believe that the lesion is in the medulla, pons, or 
spinal cord. 

Symptoms. — The most important symptom is tremor. As 
a rule, this begins in one extremity, most often the hand, and 
then spreads to the leg of the same side of the body, later to 
the arm and leg on the opposite side. At first the tremor 
is slight, becoming more marked as the disease advances ; 
the rate varies from three to five vibrations a second. Under 
4 6 



722 DISEASES OF THE NERVOUS SYSTEM. 

rare circumstances the tremor may continue during sleep. 
The tremor ceases temporarily during voluntary motion ; how- 
ever, it increases after a short period of rest. Tremor of the 
head, which was supposed by Charcot not to take place in 
this disease, has been noted by many observers. After 
some little time muscular rigidity and weakness occur in the 
affected muscles, giving rise to a characteristic attitude. The 
head is bent forward, the shoulders are stooping, the thighs 
are adducted, and the knees are more or less flexed. The 
elbows are slightly bent and the wrists extended, the face 
often becoming expressionless. The reflexes vary ; they are 
increased in some cases and diminished in others. The gait is 
often affected in a peculiar manner. The steps are short, the 
patient appearing to run ; this is known as festination ox pro- 
pulsion. The voice is often of high pitch, and the articula- 
tion may be interfered with. Mental symptoms occur in 
some of the cases, such as depression and loss of memory. 
Tachycardia has also been observed. 

Prognosis. — The disease is incurable, lasting for years. 

Treatment. — The treatment is symptomatic. Occasionally 
hyoscyamin or hyoscin controls the tremor. The general hy- 
giene of the patient should be looked after. Tonics, such as 
arsenic and strychnin, are of use. 



FACIAL HEMIATROPHY. 

Synonyms. — Neurotic atrophy of the face ; hemiatrophia 
facialis progressiva. 

Etiology. — This is a rare disease, found most frequently 
before the age of twenty, being exceedingly rare after thirty 
years of age. It is much more commonly found in the female 
than in the male sex. Heredity seems to play some part as a 
predisposing cause. It has been known to follow the acute 
infectious diseases. Trauma has also been noted as a predis- 
posing factor. In many cases no apparent cause is discern- 
ible. ' 

Pathology. — A few cases have been observed upon the 
postmortem table. In Mendel's case interstitial neuritis of the 
trigeminus and its root was found. 

Symptoms. — Usually the first thing noticed is the appear- 
ance of a whitish or yellowish patch upon the cheek, chin, or. 
forehead. This gradually increases in extent. In some in- 
stances several patches appear at the same time, which finally 



ACUTE CIRCUMSCRIBED EDEMA. 723 

coalesce. The skin in this area becomes glossy or parchment- 
like, and a depression may form which is due to atrophy of 
the subcutaneous fat. The rapidity with which these changes 
occur varies in individual cases. It is most common upon the 
cheek. The atrophic process may involve the hairy parts of 
the face, in which case the hair becomes thin and finally falls 
out. Sweating is lessened upon the affected side, and may 
finally disappear entirely. The muscles of the face become 
atrophied ; no paralysis, however, is noted. Atrophy has also 
been observed in the tongue. In long-standing cases the 
bones of the face — the frontal, the malar, and the superior 
and inferior maxillary — become atrophied. The nasal carti- 
lages and even the ear may be involved. Sensation is rarely 
affected. Associated symptoms are neuralgic pains in the dis- 
tribution of the fifth nerve and twitching of the muscles. In 
some cases the atrophy of the alveolar process becomes so 
marked that the teeth become loosened and drop out. 

Prognosis. — The disease is progressive. It may, however, 
be spontaneously arrested in some instances but it does not 
shorten life. 

Treatment. — General tonics, such as quinin, iron, arsenic, 
and strychnin, are useful. Gentle massage and the constant 
electric current are of value in allaying pain. 

ACUTE CIRCUMSCRIBED EDEMA. 

Definition. — A disease characterized by local edema, show- 
ing a tendency to recurrence at definite intervals. 

Synonyms. — Angioneurotic edema ; acute inflammatory 
edema. 

Etiology. — It may follow severe physical or mental exer- 
tion or exposure to cold, and may be associated with malaria, 
the abuse of alcohol and tobacco, and certain diseases of the 
nervous system. It is met with in hysteria, neurasthenia, and 
exophthalmic goiter. Heredity seems to play some part in 
the causation of this disease. 

Symptoms. — The onset of the disease is sudden, and is 
characterized by itching and swelling, the face being most fre- 
quently attacked, although sometimes the extremities and trunk 
may be affected. The mucous membranes are sometimes in- 
volved, so that if the gastro-intestinal mucous membrane be the 
seat of the disease, there may be vomiting, colic, and diarrhea. 
If it involve the pulmonary structure, hemoptysis may occur. 



724 DISEASES OF THE NERVOUS SYSTEM. 

Hematemesis and hemiglobinuria have also been noted. The 
swellings rarely pit upon pressure unless they have lasted for 
some time. The edema lasts from a few minutes to several 
hours, then disappears, and recurs at certain definite intervals, 
which may be days or even months. The edematous area is 
of a rose -red or dull whitish color, the area being distinctly 
outlined. It is believed that the disease is due to a vasomotor 
neurosis. 

Treatment. — If possible, the predisposing cause should be 
removed. If there be marked pain, opium is indicated. Local 
soothing applications are grateful to the patient. During the 
interval quinin and atropin are of use in preventing the recur- 
rence. 

RAYNAUD'S DISEASE. 

Definition. — Raynaud's disease is characterized by an alter- 
ation in the blood-supply with a disturbance of nutrition of 
the extremities and internal structures, which is, as a rule, 
symmetric. The disease was first described by Raynaud in 
1862. 

Synonyms. — Local syncope ; local asphyxia ; symmetric 
gangrene. 

Etiology. — The disease occurs at all ages ; it is, however, 
more frequent in middle life, and is more often found in females 
than in males, and most individuals affected are descendants 
of neurotic families. Syphilis, acute rheumatic fever, rachitis, 
and various forms of anemia have been mentioned as predis- 
posing causes. The acute infectious diseases, such as influ- 
enza, enteric fever, and also trauma, especially injury to the 
nervous system, are mentioned as exciting causes. In some 
cases there has been a history of great fatigue, fright, and 
mental emotion. 

Three varieties or degrees of intensity of the disease are 
described : (1) Local syncope; (2) local asphyxia ; (3) sym- 
metric or local gangrene. 

Local Syncope. — The peripheral parts of the fingers or toes 
and sometimes the entire hand or foot presents a white and 
glossy appearance, following fatigue or exposure. The area, 
is cold, and there is a deficient blood supply. The lobes of 
the ears and the tip of the nose are sometimes involved. The 
duration is variable, lasting from minutes to days, rarely longer 
than a few hours. After the pallor subsides a reaction sets in, 
the skin becoming red and hot. 



ERYTHRO MELALGIA. 725 

Local Asphyxia. — If the condition just described continues, 
the fingers, the toes, and the hands become congested and 
swollen. Pain, ensues, but it is not intense. The condition 
sometimes arises without the stage of local syncope, and in 
some instances there are. very severe pain and anesthesia of the 
affected area. Constitutional symptoms are not marked. At- 
tacks are produced by the slightest exposure, and may recur 
a number of times. 

Symmetric or Local Gangrene. — The fingers or, in some 
instances, a single phalanx of a finger may be the seat of the 
affection. Sometimes the toes are affected in a similar manner. 
Local gangrene may follow local asphyxia. The gangrenous 
part presents the common characteristics that are noted in 
such an area, being deeply discolored. Blebs are seen, and a 
line of demarcation plainly shows the boundary between the 
necrotic and the healthy tissues. The fingers and toes may 
slough off and a cicatrix form. In some instances the tip of 
the nose is involved, and in more extensive cases the limbs are 
affected. In rare cases even the trunk may be involved, 
there being patches of gangrene scattered here and there. In 
some instances there is extensive multiple gangrene. The 
symptoms most commonly associated with Raynaud's disease 
are hemoglobinuria, unconsciousness, or mental torpor, and 
sometimes peripheral neuritis. 

Prognosis. — The disease may recur in adults from time to 
time. Unless there be some underlying chronic ailment, as 
syringomyelia, tabes, or tuberculosis, the prognosis is favor- 
able. 

Treatment. — A change of climate is advisable in many 
cases. The local treatment consists in rest of the part. It should 
be wrapped in carded wool. Irritants or lotions should not be 
applied locally as they often increase the tendency to gan- 
grene. Nitroglycerin and amyl nitrite are recommended by 
some. Opium must be administered when the pain is severe. 

ERYTHROMELALGIA. 

Definition. — " Erythromelalgia is a chronic disease in which 
a part or parts of the body — usually one or more extremities — 
suffer with pain, flushing, and local fever, made far worse if 
the parts hang down " (Weir Mitchell). 

Synonym. — Red neuralgia. 

Etiology. — The majority of cases occur during the middle 



?26 DISEASES OF THE NERVOUS SYSTEM. 

periods of life, some few cases having been recorded between the 
ages of sixteen and twenty-one. The disease is most common 
in the male sex. It is supposed that occupations which require 
standing and exposure to varying temperatures predispose, 
such as iron-workers, engineers, seamen, letter-carriers, and 
so on. It appears from cases that have been recorded that 
previous ill health has an important bearing as an etiologic 
factor, as do also syphilis, abuse of alcohol, and trauma. 

Pathology. — The pathology of erythromelalgia is not 
definitely determined. Most observers believe it to be a per- 
ipheral irritation of the nerve -endings themselves, or primary 
inflammation of the tissues around the nerves, while others 
hold that the condition starts centrally. 

Symptoms. — The affection commonly begins with a burn- 
ing pain, usually in the sole of one foot, which is aggravated 
by standing and voluntary movements, being relieved in the 
recumbent posture and when the part is elevated. After rest 
the pain returns, and subsides less easily than upon each 
former occasion. The pain is soon followed by redness in the 
affected area, which is at first circumscribed, or several areas 
may form at the same time, which soon increase in extent. 
The veins become distended, and pulsation is noticed in the 
arteries, the pain constantly increasing in severity. Sensibility 
to heat and cold is increased in the affected part ; the reflexes, 
however, remain normal. The surface temperature shows in- 
creased heat in the part. There is some swelling and the part 
may pit upon pressure. Cold and cold applications relieve the 
pain, whereas heat increases the severity of the paroxysm. 
Relapses are common. The attacks may last from several 
hours to many years. By some authorities it is believed that 
this disease is a variety of Raynaud's disease (local syncope). 

Treatment. — The food should be nutritious and should 
be freely given. Rest is the most important factor in the treat- 
ment, the limb being placed in the horizontal position. 
Faradism is useful in the milder cases. Local applications 
of cold afford relief. 



MENIERE'S DISEASE. 

Definition. — A disease characterized by vertigo, tinnitus 
aurium, deafness, and vomiting, and due to disease of the 
internal ear. 

Synonyms. — Aural vertigo ; labyrinthine vertigo. 



OCCUPATION NEUROSIS. J 2 J 

Etiology. — The disease is rare before the thirtieth year of 
life, being more common in the male than in the female sex. 
It is supposed that gout, syphilis, degenerative changes due to 
age, and hemorrhage into the middle ear are causative factors. 
An attack may be brought on by gastric disturbances, cerebral 
or other irritations. 

Pathology. — It is probable that the symptoms of this dis- 
ease are due to disturbed function of the peripheral or central 
portions of the vestibular nerve or of the organs in relation to it. 

Symptoms. — The important symptom of the attack is ver- 
tigo, which varies considerably, being slight in some instances 
and so severe in others that the patient is compelled to 
seek the recumbent posture. In some cases the patient may 
fall abruptly to the ground. These attacks occur in parox- 
ysms at intervals of days, weeks, or months. In the severer 
cases nausea and vomiting, and sometimes unconsciousness, 
occur coincidently with the vertigo. Optic phenomena, such 
as nystagmus and diplopia, sometimes appear. Tinnitus 
aurium is usually constant, becoming worse during the par- 
oxysm. Deafness is present during the attack, but usually 
disappears during the interval. 

Prognosis. — The attack may prove fatal, but in the majority 
of instances improvement and even complete recovery occur. 

Treatment. — The bromids are useful. A counterirritant 
over the mastoid process of the temporal bone has proved 
efficient in many instances. It is always necessary to treat 
the underlying condition. Quinin and salicylate of sodium in 
large doses have been advised. Nitroglycerin and the nitrites 
are valuable if arteriosclerosis be present. 

OCCUPATION NEUROSIS. 

Definition. — This neurosis is due to the constant use of 
certain groups of muscles in occupations which necessitate 
delicate movements, producing cramp, spasm, paralysis, 
tremor, or neuralgic phenomena. 

Synonyms. — Fatigue neurosis ; occupation spasm. 

Etiology. — This neurosis is more frequent in males than 
in females. It is very commonly found in writers, the con- 
dition being called writer ' s cramp. It is also found among 
telegraph operators, stenographers, violinists, pianists, shoe- 
makers, tailors, cigar rollers, and compositors. It is worthy of 
note that writer's cramp is particularly apt to attack those 



?28 DISEASES OF THE NERVOUS SYSTEM. 

individuals who write a good hand. Neurotic temperaments, 
either hereditary or acquired, are very important predisposing 
factors. It may follow trauma or inflammation of certain 
parts of the body. Sexual excesses-and the abuse of alcohol 
and tobacco predispose. 

As yet no pathologic changes have been encountered. 

Symptoms. — The commonest form of occupation neurosis 
is writer's cramp, which is here described ; other varieties are 
similar and require no special description. The disease is 
very gradual in its onset. Writing becomes somewhat diffi- 
cult, until finally spasm develops, which may be tonic or clonic, 
and prevents the proper performance of duties. The thumb 
and index-finger are most frequently involved. Sometimes 
the first three fingers and the hand may become locked during 
the act of writing or the pen be thrown out of the hand, 
or in other instances a tremor may develop, involving the 
hand and the forearm. In some cases weakness develops in 
the hand while writing, so that rest is necessary. Pain which 
shoots up the arm may accompany this muscular debility. 
Numbness and tingling of the hand and arm may occur in 
some cases, accompanied by severe pain. There may be vaso- 
motor disturbances, the skin becoming pale and glossy or 
flushed. 

Prognosis. — The prognosis is favorable only if the partic- 
ular occupation be discontinued, for there is always a strong 
tendency to a return of the condition. 

Treatment. — Rest is the most important measure. In 
some instances it becomes necessary for the patient either to 
give up writing or to learn to write with the left hand, but 
even in such instances a cramp may develop in the left hand, 
such cases having been recorded by Duchenne and Seeligmul- 
ler. Systematic massage, electricity, hydrotherapy, and cer- 
tain drugs, such as iron, quinin, arsenic, cod-liver oil, the bro- 
mids, and hypodermics of strychnin and atropin, are useful. 

HYSTERIA. 

Definition. — Hysteria is a functional disease of the nervous 
system, characterized by a variety of symptoms which may 
simulate many diseases. 

Etiology. — The disease is very much more common in 
women than in men. Heredity plays an important part in the 
causation of the affection. It is more frequent in the extremes 



HYSTERIA. 729 

of the social scale, the poor and the rich being affected much 
more frequently than the middle classes. Injuries, such as 
railroad and other accidents, especially, according to the 
French observers, are the commonest causes of hysteria. It 
often follows the acute infectious fevers. Spoiled children are 
apt to become hysteric. Sometimes the disease shows itself 
in epidemics ; especially is this true when it is due to religious 
excitement. It has been claimed recently that it may be due 
to alcohol, tobacco, mercury, and lead, and may result from 
sexual excesses and masturbation. Bad health is also a potent 
factor in the production of the disease, or it may result from 
overwork ; this is particularly true in school-children. Grief, 
excitement, and disease of the genital organs, especially the 
ovary, give rise to hysteria. 

Pathology. — No lesions have been found in this disease. 

Symptoms. — The symptomatology of this disease is so 
varied and complex that a correct description is almost impos- 
sible. For this reason it has been found useful to give a brief 
description of a mild and a severe hysteric attack, and of the 
important symptoms which may occur either during or be- 
tween hysteric manifestations. 

Hysteric Paroxysm. — In the mild form the disease may 
begin either suddenly or after a period of malaise and nervous- 
ness, with disturbances and uneasiness in the epigastrium, also 
with palpitation and a sensation as if a ball were,rising in the 
throat [globus hystericus), causing a feeling of strangulation, 
more rarely it is preceded by convulsive movements. There 
may be dizziness and vertigo, the patient weeping and falling 
upon a chair ; there are breathlessness and crying, alternating 
with laughing. There are attacks of eructation of wind. The 
disease is frequently ushered in by spells of laughing or crying. 
The symptoms just enumerated are commonly encountered 
in the milder forms ; in the severer ones the patient falls, 
always, however, selecting such a spot as not to be injured. 
Convulsions are common. Consciousness is never entirely 
lost, and the tongue is not bitten. Clonic and tonic spasms 
occur, but they show no regularity ; the clonic may precede 
the tonic, and vice versa, and any group of muscles may be 
involved. These symptoms are accompanied by palpitation, 
tinnitus aurium, dimness of vision, and headache. As a rule, 
the temperature remains normal during the attack, or it may 
be slightly subnormal. The pupils are irregular ; sometimes 
being dilated, or at other times contracted. Often during the 



730 DISEASES OF THE NERVOUS SYSTEM. 

convulsions the body assumes an arched position (opisthot- 
onos). It is common during the convulsive seizure for the 
patient to cry, laugh, scream, and sometimes talk incoherently. 
The attacks may assume any grade between the mildest and 
the severest forms, and may so closely simulate epilepsy that 
the physician who depends entirely upon the account of friends 
may for a long time be in doubt as to the diagnosis. 

Sensory Phenomena. — Anesthesia, especially of the skin, 
is one of the most important phenomena. The senses of 
touch, of pain, and of temperature may be diminished or 
entirely abolished. In the severer cases there may even be 
anesthesia of the deeper parts. Hemianesthesia is common. 
Sometimes the anesthesia is distributed in different parts of 
the body with normal parts between ; in rare instances the 
whole body may be affected. 

Hyperesthesia and hyperalgesia are commonly encountered. 
Pain in the head is often severe, sometimes described as though 
a nail were driven through it ; this has been called the hysteric 
clavus. Tenderness over the supra- and infra-orbital foramina 
is frequently noted, and pressure in this region may produce 
a hysteric attack (convulsion). The spine is often tender, 
particularly at certain points, and pressure in this region may 
also produce attacks. Similar areas of tenderness are noted 
in the inguinal region, especially upon the left side, in women 
as well as in men. Tender points are also met with on the 
limbs. 

Motor Phenomena. — There is frequently inability to stand 
or walk ; the muscular power, however, being retained while 
in the recumbent posture. The reflexes and electric reactions 
and the sensations are not impaired. A condition described as 
astasia abasia is characterized by the symptoms just enumer- 
ated, and is probably of hysteric origin ; however, cases have 
been recorded which have been associated with chorea, epi- 
lepsy, and psychosis. Muscular wasting is usually not appa- 
rent in motor hysteric disturbances, but in rare instances 
wasting does occur, when it is general and not accompanied 
by fibrillary contractions. The wasting may come on and 
disappear rapidly. Various contractures are associated, which 
may be monoplegias, hemiplegias, or paraplegias. The patellar 
reflex is usually exaggerated. Babinski has described a re- 
flex which normally is produced by gentle friction of the sole 
of the foot, causing the toes to become flexed, while if there 
be disease of the pyramidal tract, an extension of the toes, 



HYSTERIA. 731 

especially the great toe, occurs. These signs are said to be 
always absent in hysteria. 

Reflex Phenomena. — The reflexes are never absent in hys- 
teria, and are usually exaggerated, in some instances being 
normal. The presence of well-developed ankle clonus is not a 
manifestation of hysteria, but a slight ankle clonus may be 
encountered in the disease. There may be paralysis of the 
sphincters, giving rise to retention of urine, and characterized 
by intermissions. 

Tremors. — Several varieties occur ; the commonest consist 
in rapid tremor of the hands, particularly noted during ex- 
amination by the physician. There may also be tremor of 
the head and tongue. A coarse tremor is sometimes ob- 
served in the wrist and forearm, occasionally also affecting 
the legs. 

Ocular Symptoms. — Ptosis may occur, and may be either 
unilateral or bilateral. There maybe strabismus. Conjugate 
movement and diplopia are symptoms. Nystagmus is rare 
and the Argyll Robertson pupil is never noted in this dis- 
ease. Photophobia is common, the patient preferring to be 
in a darkened room. There is frequently concentric nar- 
rowing of the visual field, and color sense is sometimes im- 
paired and there is reversal of the fields. Some time after 
the hysteric attacks the visual field may return to its normal 
condition. Scotomata and hemianopsia are extremely rare ; 
when present, organic disease should be suspected. 

Auditory Symptoms. — Tinnitus aurium and vertigo are 
common. Occasionally hysteric deafness has occurred. 

Aphonia. — This is common, the patient not being able to 
speak louder than a whisper. Mutism is rare. 

Other Symptoms. — A harsh, unproductive cough is some- 
times noted in this disease, and is known as the hysteric 
cougli, there being no lesion of the larynx or lungs. The 
will-power is impaired. There may be noises that simulate 
cries of the lower animals. Even epidemics of this kind 
have been noted. Persistent hiccup, sneezing, yawning, 
dyspnea, and orthopnea without cyanosis have been observed. 
Dysphasia, eructations of wind, borborygmi, vomiting, nausea, 
and difficult swallowing are all symptoms. Tenderness of the 
joints, unaccompanied by inflammation, is present, the large 
joints being most frequently affected. Tenderness of the 
mammae is not common ; rarely upon palpation a tumor may 
be detected. Spurious tumors are sometimes encountered in 



732 DISEASES OF THE NERVOUS SYSTEM. 

the abdomen, which disappear when the patient is under an 
anesthetic ; these are known as phantom tumors. Pseudo- 
angina pectoris, palpitation, and vasomotor disturbances are 
common. In very rare instances hemorrhages are noted in 
the skin and from some of the mucous surfaces, so that 
hemoptysis and hematemesis may be encountered ; however, 
this is an extremely rare condition and should be ascribed to 
hysteria only when local lesions can not be elicited and other 
hysteric manifestations are present. Ischemia and edema are 
also present in some cases. Mania, double consciousness, and 
hysteric insanity are rare manifestations. 

Hysteric Fever. — Slight fever may be noted in hysteria. 
The temperature may be high for a considerable length of 
time or there may be paroxysmal variations, or it may vary in 
different portions of the body, — for example, being normal in 
one axilla and subnormal in the other, — but it is commonly 
normal. It is said that hysteric fever is not accompanied by 
the tissue changes that are so usual in the ordinary fevers, 
therefore the temperature sometimes reaches very high points ; 
i io° F., 112° F., and even 1 18° F. have been recorded. The 
fever is frequently accompanied by abdominal and joint pains, 
so that under these conditions one must exclude organic 
lesions. Malingering should not be forgotten as a possible 
cause for apparent pyrexia, as not infrequently hospital patients 
are skilful in the handling of a thermometer. 

Prognosis. — As a rule, the prognosis as to life is favorable. 
Death has been recorded by Charcot and Weir Mitchell, but 
this is extremely rare. 

Treatment. — The physician must not be harsh in his treat- 
ment, but should always exercise tact, firmness, and kindness, 
and the patient should have faith in the medical adviser. 
The diet should be light but nutritious. Systematic exercise 
and sunshine are often of great value in the treatment. The 
rest-cure, as introduced by Weir Mitchell, is of benefit. Hy- 
drotherapy and electricity are also indicated. Valerian, asafe- 
tida, and the bromids are of use. For the pain opium should 
not be employed ; in fact, all narcotics are to be avoided, as 
there is great danger of acquring the drug habit. For the pain 
counterirritation is often of value, the thermocautery being 
applicable in some cases. . 



NEURASTHENIA. 733 



NEURASTHENIA. 

Definition. — Neurasthenia is a functional disease of the 
nervous system characterized by mental and bodily weakness. 

Etiology. — This is particularly a disease of centers of cul- 
ture, affecting both sexes ; the male sex, however, being 
slightly more often affected than the female. It is most fre- 
quent between the ages of twenty and fifty. Heredity plays 
an important part in this disease. Nervous parents often 
transmit their constitutional fault to their children ; however, 
heredity is not always of prime importance in the causation of 
this disease. Worry, fatigue, excitement, and excessive mental 
or bodily strain are important causative factors. The most 
frequent causes among men have been unhappy marriages, 
financial anxiety, excessive study, and fear of venereal disease. 
Among women the causes have also been unhappy marriages, 
family cares, and dread of epidemic diseases, particularly 
cholera. The disease is particularly prevalent in the United 
States, although it is also frequent in parts of Europe. It is 
very common among the Jews. It is a disease of the well-to- 
do and of the educated classes. Of the acute infectious dis- 
eases, neurasthenia most frequently follows influenza, enteric 
fever, and malaria. Of the chronic infectious diseases, the 
most important as a causative factor is syphilis. The abuse 
of chloral hydrate, morphin, cocain, tobacco, tea, and coffee 
have been known to give rise to the disease. It may follow 
pregnancy or chronic local diseases, particularly chronic gas- 
trointestinal disease and diseases of the genitals. Floating 
kidney and dropping of other viscera have often been observed 
with this disease. Systematic attempts at curing obesity, 
sexual excesses, masturbation, and dietetic errors may give 
rise to neurasthenia. Various accidents, particularly railroad 
accidents, may cause the disease (traumatic neurasthenia). 

Symptoms. — The symptomatology is very complex ; in- 
deed, so varied are its phenomena that special groups of cases 
have been differentiated, according to the predominance of cer- 
tain symptoms. They are the cerebral, the spinal, the gastro- 
intestinal, the cardiac, and the sexual varieties. The general 
symptoms are despondency, fatigue upon slight exertion, both 
bodily and mental, and loss of weight ; in some instances 
anemia, loss of sleep, and mental emotion are also frequent 
symptoms. There is particularly fear of being in a large 
open space (agoraphobia), and the fear of being shut up, 



734 DISEASES OF THE NERVOUS SYSTEM. 

especially in crowded places (claustrophobia), these conditions 
being quite characteristic of the disease. The patients fre- 
quently relate to the physician their various symptoms, and 
often take note of them, reading the report to the medical 
adviser. This was called by Charcot " L' homme a petitis 
papiers." Hyperesthesia, vertigo, and depression are all com- 
mon symptoms. The temperature is usually subnormal. The 
appetite is variable, and constipation is the rule. There is 
much irritability of temper. 

The Cerebral Variety. — Headache, sleeplessness, inability 
to work, worry, depression, and anxiety are common symptoms 
in the cerebral type. There are very frequently ocular phe- 
nomena, reading tiring the patient. Sleeplessness is the rule, 
but in some instances the patient may sleep well. Disagree- 
able dreams are common. The patient is nearly always better 
in the evening and worse toward the morning hours. Flashes 
of heat and cold on the surface of the body, anemia, palpita- 
tion of the heart, and sweating are usual symptoms. Fre- 
quently there is a sensation of tenderness on pressure of the 
head. 

The Spinal Variety. — Great weakness, especially upon 
rising in the morning, muscular stiffness, pain, and fatigue are 
common symptoms in spinal neurasthenia. It often requires 
many days for the patient to become rested, and fatigue again 
develops upon very slight exertion. Backache and tender- 
ness at certain points along the spine are common symptoms. 
The deep reflexes are exaggerated. Ankle clonus is some- 
times present. Paresthesia, especially formication, is a common 
complaint. There are sensations of heat, cold, and tingling 
in various parts of the body. Not infrequently symptoms of 
lightning pains are encountered, which in some degree simu- 
late the pains of tabes ; this pain, however, may be localized 
to distinct nerve-trunks, which are always tender upon pres- 
sure. Rarely Romberg's sign is present. Coordination may 
be somewhat disturbed, so that the acts of writing and talk- 
ing are imperfectly performed. The nervous form of astasia 
abasia, as described under Hysteria, is present in this variety 
of neurasthenia. 

The Gastrointestinal Variety. — The gastro -intestinal 
variety is characterized by symptoms which particularly relate 
to the gastro-intestinal tract. Hyperacidity, pyrosis, nausea, 
vomiting, disturbed sleep, irritability of temper, sensations of 
flatness in the epigastrium, a bitter taste in the mouth in the 



NEURASTHENIA. 735 

morning upon awakening, anorexia alternating with bulimia, 
constipation alternating with diarrhea, flatulency, occasionally 
tenesmus, and often rapid loss of weight are the common 
symptoms. Floating kidney and enteroptosis are frequently 
associated with the gastro-intestinal variety. Headache is a 
veiy common symptom. 

The Cardiac Variety. — Palpitation of the heart upon slight 
exertion or slight excitement, precordial distress, pseudo-angina 
pectoris, and vertigo are symptoms of particular prominence. 
Arrhythmia and powerful pulsation of the arteries, particularly 
of the abdominal aorta, are common symptoms, these mani- 
festations occurring without obvious changes in the walls of 
the blood-vessels. There is an absence of valvular disease. 
A capillary pulse may even be present in some instances. The 
extremities are frequently cold, and flashes of heat in the head 
are common. 

The Sexual Variety. — This form of neurasthenia is charac- 
terized by spermatorrhea, nocturnal emissions, masturbation, 
perverted sexual desires, impotence, and painful testicle or 
ovary. Quacks flourish upon these poor individuals, their 
pamphlets and circulars being the net by which the victims 
are drawn into their traps. 

Prognosis. — Under proper treatment the prognosis is favor- 
able. It is well expressed by Allbutt in the following terms : 
" The patient who can lift his eyes to the future will recover ; 
he whose thoughts live in the past is on the broad road to 
lunacy." The earlier the case comes under the observation 
of the physician, the more hopeful the prognosis. 

Treatment. — Of all diseases, neurasthenia requires study 
of the individual case. The following methods of treatment 
have been very successful. The rest cure is applicable in many 
cases, while in others a change of climate is of great benefit. 
Hydrotherapy, electricity, massage, and hypnotism have all 
been of value in the treatment. The diet must be suited 
to the case, and must be easy of digestion. Milk diet is 
sometimes necessary. The bromids are of particular value 
in the cerebral variety. In gastric cases, arsenic in the form 
of Fowler's solution is of service. Syrup of the hypophos- 
phites and valerian are also useful. Caffein, hyoscin, and 
phenacetin are of benefit. Opium and other hypnotics, if used 
at all, must be administered with great caution. Alcohol may 
be given sparingly. Iron and cod-liver oil may be used. Sys- 
tematic exercise is of great benefit. 



PART IX. 
DISEASES OF THE MUSCLES 



MYOSITIS, 

Definition. — Inflammation of the muscles. 

Etiology. — This may be either primary or secondary. 
When primary, it is sometimes known as acute poliomyelitis. 
It may be due to trauma or to the invasion by parasites of the 
muscles, particularly by the trichinae. Secondary inflammatory 
conditions of the muscles arise from acute and chronic dis- 
eases, in which there is either general or local parenchymatous 
or interstitial change, this being either suppurative or non- 
suppurative. Myositis often arises during the course of the 
specific fevers, such as enteric fever, typhus fever, and variola. 
Infection of the muscles takes place in the course of pyemia, 
ulcerative endocarditis, glanders, puerperal fever, actinomyco- 
sis, erysipelas, gonorrhea, and from some wounds. Finally, 
myositis is often due to syphilis. 

ACUTE POLYMYOSITIS, 

Definition. — Acute inflammation of any muscle group. 

Etiology. — The disease is said to be due either to the 
influence of toxins or to an animal parasite. It has oc- 
curred in the course of pulmonary tuberculosis and diabetes. 
The disease is more common in males than in females, and 
does not occur in children. 

Pathology. ^Any of the muscles of the body may be im- 
plicated ; the masseter and ocular muscles, however, commonly 
escape. The muscle-tissue is swollen and yellowish-white in 
color ; occasionally there are brownish-red patches covering 
this decolorized area. Often hemorrhages may be noted. 
The muscle is soft and friable. 

736 



MYOTONIA CONGENITA. 737 

Symptoms. — The disease begins gradually with weakness, 
anorexia, headache, and occasionally vomiting, accompanied 
by subfebrile temperature without chills. These symptoms 
may be preceded by local pain, cramp-like in nature, with 
tenderness particularly in the arms or legs. The pain may 
become so severe that it is impossible for voluntary move- 
ments to take place in the muscle, but the joints are not 
affected. Soon muscles of other parts of the body become 
affected, such as the intercostals, the diaphragm, and the mus- 
cles of deglutition. Sensation is retained, the nerves not being 
tender upon pressure. The electric reactions of the muscle 
are normal. Stomatitis frequently occurs in the course of 
the disease. The spleen is commonly found enlarged. In 
the milder cases recovery takes place in the course of a few 
weeks ; in the severer forms atrophy of the muscles may be 
found after the acute process has subsided, in which case the 
electric reactions are changed ; and in the severest cases death 
may occur on account of the implication of the muscles of 
respiration, and bronchopneumonia is apt to arise. 

Treatment. — Treatment should be directed to relief of the 
pain. In convalescence tonics are necessary. 



MYOSITIS OSSIFICANS. 

This is a rare disease. By many it is regarded as an in- 
flammation, and by others as a new growth. It has followed 
slight injury. Ossification develops later, forming branching 
fragments, which may be either free or attached to the bone. 
The process may occur in the back, neck, and thorax, and 
gradually extend to all parts of the body. The entire mus- 
cular structure may become rigid. As a rule, this disease 
begins in early youth. 



MYOTONIA CONGENITA. 

Definition. — Thomsen's disease is characterized by pro- 
longed contraction of the muscles concerned in voluntary 
movements when brought into action. 

It is said that Thomsen's disease is the rarest in medicine. 
It was quite accurately described by Dr. Thomsen, a Danish 
physician, who suffered from the malady. 

Synonym. — Thomsen's disease. 

Etiology. — Heredity seems to play an important part. It 
47 



73 8 DISEASES OF THE MUSCLES. 

occurs most frequently about the age of twenty, and is more 
common in males than in females. A family history of 
neurotic temperament plays some part in the etiology. 

Pathology. — The muscle-fibers have been found hyper- 
trophied. 

Symptoms. — The most important symptom of the condition 
is that upon voluntary movement the contraction of the muscle 
which the patient desires to move is slower than normal, and 
when contracted remains so for some seconds ; this contraction 
may be so strong that the muscles which are apposed can not 
overcome it. This is well illustrated in the voluntary muscles 
of the hand. It requires some time for the patient to flex the 
fingers ; the contraction of these muscles also being marked, 
it requiring ten or fifteen seconds to perform this act. The 
arm or the muscles of the face, those concerned in the 
moving of the jaw, the muscles of the thigh, the legs, the 
neck, and the back may all be affected. The muscles con- 
cerned in the acts of respiration, deglutition, micturition, defe- 
cation, and parturition are not affected. Sensory disturbances 
are not present, both the superficial and deep reflexes are 
normal. 

Prognosis. — The prognosis is good as far as life is con- 
cerned, but the condition is incurable. 

Treatment. — No treatment has any effect upon this dis- 
ease. Thomsen thought that the more active his life, the less 
he suffered from the disease. 



IDIOPATHIC MUSCULAR ATROPHY AND 
HYPERTROPHY. 

Definition. — A disease characterized by atrophy and hyper- 
trophy of various groups of muscles not associated with 
diseases of the anterior cornua of the spinal cord. 

The disease appears to be congenital, although in many in- 
stances it does not show itself for some time after birth. 

Synonyms. — Progressive muscular dystrophy ; primary 
progressive myopathy. 

Pathology. — The lesions are found in the muscles, the cen- 
tral nervous system not being affected. Interstitial change is 
noted in the muscles affected, there being either a deposit of 
fat or new-formed fibrous tissue. The muscle-fiber rarely re- 
veals fatty degeneration or waxy degeneration. According to 
Erb, the primary changes are in the muscle-fiber itself. 



IDIOPATHIC MUSCULAR ATROPHY AND HYPERTROPHY. 739 

Diagnosis. — The chief points in the diagnosis are the 
absence of the fibrillary contractions, the fact that sensation is 
not altered, and the absence of reaction of degeneration to 
electric testing. The onset is slow, affecting various groups 
of muscles. 

Prognosis. — The prognosis is unfavorable as regards cure, 
although the disease may last for a number of years, the 
patient usually dying of some complication. 

Treatment. — The most important measures are careful 
hygiene and the administration of tonics to sustain the general 
strength of the patient. Drugs seem to have no influence 
upon the disease. Massage may be employed and light ex- 
ercise should be encouraged. 

There are several varieties of the disease, all of them, how- 
ever, characterized by lesions of the muscles without disease 
of the central nervous system. 

Three varieties are described: (i) Pseudohypertrophic 
muscular paralysis. (2) The juvenile form of progressive 
muscular atrophy. (3) The facioscapulohumeral form. 

L PSEUDOHYPERTROPHIC MUSCULAR PARALYSIS* 

Etiology. — It is most common in childhood, although the 
appearance of the disease may be delayed anywhere from 
childhood up to puberty. It is more frequent in the male 
than in the female sex, and heredity seems to play an impor- 
tant part. The disease is transmitted through the females, 
but principally attacks the males. It sometimes skips genera- 
tions (atavism). 

Symptoms. — An early symptom of the disease is diffi- 
culty in walking. The muscles apparently become very 
large, so that not infrequently friends seek the advice of the 
physician on account of this peculiarity. It is a peculiar fact 
that some muscles have a tendency to atrophy, while some 
have a tendency to become enlarged. The muscles of the 
calf are quite large. There is difficulty in attempting to stand 
on tiptoe, showing that the muscles have lost their power to 
some extent. The anterior tibials, the gluteus maximus, and 
the extensors of the thigh are also enlarged, while the flexors 
of the knee and hip-joint, also the adductors of the hip-joint, 
are atrophied. 

The following muscles are hypertrophied : The deltoid (this 
showing the affection prominently), the supraspinatus and infra- 



740 DISEASES OF THE MUSCLES. 

spinatus, the triceps, the extensors of the wrist and fingers, 
the muscles of the tongue, and the masseter. The following 
muscles are usually atrophied : The lower half of the pec- 
toralis major, the latissimus dorsi, and the biceps. The fol- 
lowing muscle groups are usually not affected : The trapezius, 
the rhomboideus, the serratus magnus, and the muscles of the 
hand, forearm, face, and neck. 

There is difficulty in walking and in arising when in the 
sitting posture. The gait is peculiar, the patient throwing 
the knee in advance of the foot and throwing the shoulders 
from one side to the other. In the standing posture the feet 
are widely separated, so as to give the patient a better base 
of support. Contractures of the muscles sometimes occur 
early in the disease, which are due to the fibrous connective 
tissue in the muscles. The electric reactions are not altered 
at first, but later the electric contraction diminishes to the 
faradic and galvanic currents. Very late in the disease the 
reaction to the battery is entirely absent. The knee-jerk 
is at first normal, but it diminishes as the disease progresses. 
Fibrillary contraction is absent. Sensory disturbances are 
not encountered. 

II. THE JUVENILE FORM OF PROGRESSIVE MUSCULAR 
ATROPHY, 

This form differs from the first variety, just described, in 
that the disease occurs later in life, the muscles being wasted 
instead of being enlarged. 

HI. THE FACIOSCAPULOHUMERAL FORM. 

This form is probably the same disease as the juvenile 
variety, differing only in that the muscles of the face are in- 
volved, and therefore they are described together. 

Etiology. — Sex plays no part in the causation, both sexes 
being equally affected. There is a marked hereditary ten- 
dency. The disease is more common in childhood than in 
the very young or in adult life. 

Symptoms. — In the juvenile form described by Erb the 
muscles of the shoulder and upper arm are first affected, re- 
vealing marked wasting and diminished function or paralysis, 
the muscles of the face usually escaping. Fibrillary con- 
tractions are absent and the reflexes disappear as the disease 
advances. In the facioscapulohumeral variety the atrophy most 
often begins in the muscles of the face. In this variety there 



IDIOPATHIC MUSCULAR ATROPHY AND HYPERTROPHY. 74 1 

is often difficulty in closing the eyes. The orbicularis palpe- 
brarum is atrophied, while the muscles of the eyeball usually 
escape. The orbicularis oris and the levator anguli oris are 
wasted. Many of the other muscles of the face are also 
affected in some cases. Most of the muscles of the shoulder- 
girdle and arm are also atrophied. Fibrillary contractions 
are absent, the electric reactions are slightly diminished, and 
the knee-jerks are normal until late in the disease. Sensory 
disturbances are not encountered. The course of the disease 
is prolonged. 



PART X. 
INTOXICATIONS AND SUNSTROKE 



POISONING BY FOOD; PTOMAIN-POISONING. 

Food may act as a poison in one of two ways — either as a 
result of bacteria which have gained access to the food and 
produced their ptomains, or through an admixture of chemic 
poisons either organic or inorganic. The form of food- 
poisoning from chemicals of an organic or inorganic variety 
belongs to the domain of toxicology. 

Food-poisoning due to bacteria may occur in one of three 
ways : First, the food may have undergone putrefactive 
changes, with the formation of toxic chemic substances (pto- 
mains), before having been eaten, in which case the symptoms 
are extremely rapid in their onset. Second, the food may 
contain pathogenic micro-organisms, which, if they have been 
swallowed, set up toxic phenomena ; in most instances of this 
sort there is a period of incubation, and this often precedes 
local lesions elsewhere than in the intestinal tract. Third, 
putrefaction may occur in the large or small intestine, the 
food having been in apparently good condition when swallowed. 

Various ptomains, which were first studied by Selmi and 
later by Brieger, have been found in the cadaver. Cadaverin, 
pufrescin, and cholin are only slightly poisonous. A mus- 
carin-like alkaloid that occurs in decomposing flesh when 
swallowed gives rise to profuse diarrhea, lacrimation, salivation, 
and sweating, in which clonic spasms occur, with heart-failure. 

Sepsin, obtained from decomposing yeast, when introduced 
into the system, causes vomiting and bloody diarrhea, Myda- 
lein, derived from the human cadaver, causes a rise in temper- 
ature with dilatation of the pupil, paralysis, and convulsions. 
None of the other ptomains, as a rule, produces fever. 

742 



GRAIX-POISONIXG. 743 

When fever occurs, it is due to the albumoses or digested 
proteids. 

Symptoms of Food-poisoning. — The symptoms produced 
may be due to the bacterium itself, to its chemic products, or 
to a combination of both. If the symptoms be due to the 
bacterium itself, a period of incubation occurs that varies as 
regards the individual micro-organism. The onset of the 
disease is sudden. The patient is frequently seized with chill, 
abdominal pain, and muscular weakness. Vomiting and vertigo 
are frequent symptoms. Diarrhea with offensive stools, which 
may be bloody, accompanied by great thirst, is a prominent 
and almost invariable symptom. Some febrile reaction almost 
always occurs, the temperature in individual cases, however, 
showing great fluctuation. The pulse is rapid ; there are 
muscular twitching, disturbance of vision, with dilatation of 
the pupils, and drowsiness. Urticarial and erythematous 
rashes show themselves. If death takes place, it is preceded 
by coma. Convalescence is often protracted. 

Treatment. — A brisk purgative should be administered : I 
ounce of castor oil or from 3 to 5 grains of calomel, as it is 
necessary to rid the intestinal tract of the poisonous material. 
Opium is necessary to relieve the pain ; and when there is 
profuse diarrhea, with offensive stools, intestinal antiseptics, 
such as beta-naphthol and salol, are of value. Stimulants are 
necessary for the prostration and for the cardiac asthenia. 



GRAIN-POISONING. 

This is an extremely rare condition. The principal effects 
of the poison usually fall upon the brain and nervous system, 
especially upon the spinal cord. 

Ergotism. — Etiology. — The disease is due to the microbe 
known as the claviceps purpurea. Predisposing factors are 
starvation and ill health. 

Symptoms. — The symptomatology shows itself in one of 
two varieties — first, the spasmodic or convulsive ; and, second, 
the gangrenous variety. The acute form of the disease is 
most common in children. The symptoms are giddiness, de- 
pression of spirits, formication, with clonic and tonic spasms, 
colicky pains, tympanites, precordial distress, violent vomiting 
with purging, stupor, occasionally a vesicular eruption, and in 
the rapid cases the symptoms frequently resemble those of 
Asiatic cholera. When convalescence follows, which is rare, 



744 INTOXICATIONS AND SUNSTROKE. 

it is prolonged and tedious, and sequels, such as epilepsy and 
cataract, appear. The gangrenous variety may also set in 
acutely, although the destruction of the limbs requires a 
longer time. Pain penetrates the affected part, but in some 
rare instances pain is entirely absent. An erysipelatoid erup- 
tion may precede the lividity of the part, but this is unusual, 
the lividity passing into a darker color, the limbs soon be- 
coming black. Generally the gangrene is of the dry variety. 
More than one part of the body may be affected, and one part 
after another and one organ after another may be involved, 
until death takes place. If the disease be arrested, the patient 
may recover with the loss of a hand, foot, or limb. In some 
other cases the disease is more chronic, and in others there is 
a mixture of the spasmodic and gangrenous forms. 

Diagnosis. — If the condition be epidemic, there is no dif- 
ficulty in the recognition, but sporadic cases give rise to great 
difficulty in diagnosis. It has been claimed by Ehlers that 
Raynaud's disease, acrodynia, and erythromelalgia are only 
varieties of ergotism. 

Prognosis. — The mortality in severe epidemics is 60 °fo , and 
during less severe epidemics it may be about 10^. 

Treatment. — There is no specific remedy, the treatment 
being entirely symptomatic. 

Pellagra has already been described. (See p. 683.) 

Lathyrism. — This is a name given by Cantani to an affec- 
tion produced by diseased grain. The disease has been noted 
in parts of France, Italy, and Egypt. It follows an almost 
exclusive diet of chick-pea, with unsanitary conditions of life. 
These appear to be the most prominent predisposing causes. 

Symptoms. — The symptoms come on rapidly, the patient 
being unable to arise from his bed in the morning, previously 
being in an apparently healthy condition. There is a stiff and 
creepy sensation in the limbs, and often a pain in the back is 
characteristic. Soon an unsteadiness in the hands, associated 
with tremor, occurs upon rising, and a peculiar gait is noted, 
resembling spastic paraplegia. Occasionally the gait may 
have an ataxic character, and shooting pains and great dis- 
turbance of sensation occur, such as hyperesthesia, pares- 
thesia, and anesthesia. The tendon reflexes, however, are 
exaggerated. These symptoms require from four to five 
weeks to attain their full development. As a rule, the sphinc- 
ters are not affected. 

Prognosis. — The prognosis is generally favorable. If the 



SNAKE POISON. 745 

diet be changed soon enough before marked alterations take 
place in the cord, recovery may result. 

Treatment. — -The treatment consists in removing the cause, 
in putting the patient amid the best sanitary surroundings, and 
in administering tonics and stimulants. 



MUSHROOM-POISONING. 

This results from the eating of certain fungi which do not 
belong to the edible variety of mushroom, the toxic agent 
being muscarin, which is similar to those substances known 
as ptomains. Cholin is a substance closely allied to muscarin, 
and may also produce the same toxic effects. 

Symptoms. — Shortly after a meal of poisonous mush- 
rooms vomiting, diarrhea, severe cramps, and intense prostra- 
tion promptly develop. Some disturbance of vision is com- 
mon, muscarin having a myotic effect. Salivation is frequent, 
but perspiration is arrested. Muscarin paralyzes the cardiac 
muscle. In children convulsions are frequent. 

Diagnosis. — This depends upon the contraction of the 
pupils, and upon the appearance of the fungus in the vomited 
material or in the stools. 

Prognosis. — Recovery frequently occurs unless an enor- 
mous proportion of poisonous mushroom be taken and vomit- 
ing and diarrhea do not take place. Collapse and heart failure 
are the principal causes of death. 

Treatment. — The stomach should be emptied and stimu- 
lants promptly administered, preferably hypodermically. The 
physiologic antagonist to muscarin is atropin, hence a hypo- 
dermic injection of atropin is almost a specific. Other symp- 
toms must be treated as they arise. 



SNAKE POISON. 

Venomous snakes exist in nearly all the temperate and 
tropical parts of the world. 

The venom may enter the body in different ways. It may 
enter through the subcutaneous tissue by means of the bite, 
thus reaching the circulation by absorption by the blood- 
vessels. If introduced directly into a vein, the effects occur 
much more quickly. Venom taken by the mouth, with the 
exception of the cobra venom, does not seem capable of pro- 
ducing poisonous effects, providing there is no abrasion in the 



74-6 INTOXICATIONS AND SUNSTROKE. 

mucous membrane of the alimentary canal. The venom is 
excreted particularly by the kidney and to a slight extent by 
the salivary glands of the reptile. 

Symptoms of Snake-bite. — Cobra=bite. — Immediately 
after a bite there is a sensation of burning and stinging in the 
wound, which soon becomes red, tender, and swollen. In 
the course of a half-hour constitutional symptoms begin 
to manifest themselves, such as desire to sleep, a feeling of 
intoxication, and weakness in the legs, which increases 
until the patient is unable to stand. Paralysis of the tongue, 
with profuse salivation, and inability to speak or swallow 
soon appear. With these symptoms there are nausea and 
vomiting. The signs of paralysis rapidly spread. The 
breathing becomes slower and the cardiac action quicker. 
After a while convulsions may occur ; this is not necessarily 
unfavorable. The breathing ceases and the heart stops. 
During all this time the pupil is contracted, but reacts to light. 
Hemorrhages may occur from the mucous surfaces. The urine 
never becomes albuminous. If the patient recovers, conva- 
lescence is rapid. 

Rattlesnake. — After the inoculation of the poison, severe 
pain takes place in the wound, accompanied by great swelling 
and discoloration, often slight bleeding occurring from the 
wound. Constitutional symptoms may appear within fifteen 
minutes. There is marked prostration, staggering gait, 
nausea, vomiting, cold sweats, dilated pupil, quick and feeble 
pulse. In a condition of this sort the patient may die within 
twelve hours after receiving the bite of a rattlesnake. If re- 
covery occur from the depression, the swelling and discolora- 
tion rapidly extend, and there is a rise of temperature. The 
face becomes puffy and there are marked prostration and 
rapid syncope. Labored respiration, quick and feeble pulse, 
and a clear mind are characteristic. Occasionally there is 
restlessness, which may be preceded by convulsions. Sup- 
puration may take place in the wound, and even gangrene 
may form, to which the patient may succumb several weeks 
afterward. On the other hand, the swelling may become less, 
the pain may gradually ameliorate, and recovery may occur. 
As a rule, when recovery occurs, it is rapid and will result in 
a few hours, even after the patient has been apparently in a 
moribund condition. 

Prognosis.- — The prognosis depends upon whether treat- 
ment has been prompt, and whether the reptile has embedded 



ACUTE ALCOHOLISM. 747 

its fangs and discharged the full amount of its poison into the 
system. The cobra venom is perhaps the most fatal. 

Treatment. — The treatment should be considered under 
three headings : (i) To lessen the absorption of the poison ; 
(2) to counteract the effect of the poison upon the system ; (3) 
to hasten excretion. 

A ligature should be tightly applied above the wound. 
Free incision must then be made into the subcutaneous parts 
around the wound. An elastic bandage should be applied 
downward several times. The application of nitric acid or of 
the actual cautery has been advised by Fraser. If the point of 
inoculation be a finger or toe, amputation after the use of the 
ligature is justifiable in some cases. The ligature can scarcely 
be retained for more than half an hour, as it produces great 
pain. It may then be removed for a few minutes, and when 
circulation has established itself, it can be reapplied. This 
process can be performed several times. Sucking the wound 
is to be recommended ; precaution should always be taken to 
ascertain whether the mucous membrane of the mouth is not 
injured. The remedies which have been advised to counter- 
act the effect upon the general system are intravenous injec- 
tions of- antitoxin and hypodermic injections of strychnin. 
Small doses of alcohol as a stimulant are useful, but ex- 
ceedingly large doses would in themselves prove harmful. 
Walking the patient about is also useless. Recently anti- 
venomous serum has been introduced by Dr. Calmette, which 
is said to be exceedingly effective. To hasten the excretion 
of the venom diuretics may be used. 

ACUTE ALCOHOLISM. 

The action of alcohol upon the system varies greatly in dif- 
ferent individuals, both as regards dosage and effect. Some 
persons are extremely susceptible to its effects, small amounts 
giving rise to toxic phenomena. Others require large amounts 
to produce the poisonous effects. 

Etiology. — Among the predisposing causes are idiosyn- 
crasies and susceptibility, which may be due to heredity. The 
hereditary taint is probably responsible to a great extent for 
the use of alcohol. In individuals descendants of alcoholics 
the offspring are apt to be neurotic. Occupation is also a 
predisposing cause of some importance, as those engaged in 
the sale of liquors, those exposed to the vicissitudes of 



74$ INTOXICATIONS AND SUNSTROKE. 

weather, as cab-drivers, soldiers, sailors, and so on. The in- 
habitants of cold or temperate climates are more addicted to 
the use of alcohol than those living in warm climates. 

Among the exciting causes may be mentioned mental de- 
pression, as from deaths of relatives, loss of money, failing 
health, pain, and so on. 

Symptoms. — If a large quantity of alcohol be partaken of 
at one time, death may take place rapidly ; this is, however, 
rare. It more frequently occurs that collapse results after the 
ingestion of large quantities of alcohol. As absorption takes 
place, coma develops, which is due to the narcotic effect of the 
alcohol upon the brain. The unconsciousness is not always 
complete, as in some cases the patient may be aroused by the 
use of the battery or a slap in the face, and so on. Paralysis 
does not occur. Usually there is some cyanosis of the skin or 
there may be flushing. The respiration is stertorous and the 
pulse full. The breath has an alcoholic odor, but not too 
much importance should be placed upon this, as an epileptic 
or a person having an apoplectic stroke may have partaken of 
liquor previous to the coming on of the symptoms. Convul- 
sions are extremely rare. The temperature, as a rule, is 
normal or subnormal, and the pupils are dilated. > Prompt 
treatment is most often followed by recovery. 

Treatment. — If coma occur from alcohol, the stomach 
should be promptly emptied by lavage. Attempts should be 
made to arouse the patient by the use of electricity ; strong 
coffee should then be given, and the patient should be placed 
in a warm bed. Collapse should be treated by hot applica- 
tions and hypodermics of strychnin. When recovery has taken 
place, the gastritis, which is certain to follow, will require treat- 
ment. 

CHRONIC ALCOHOLISM. 

This results from the long-continued use of alcohol, and 
especially affects the nervous and digestive systems. At 
first functional, and later organic changes appear in different 
organs. 

Symptoms. — The onset is insidious, the symptoms being 
fatigue, unwillingness to work, and loss of energy. There is 
malaise, headache, general depression, mental depression, loss 
of sleep, and tremor of the hands, lips, and tongue. The 
tremor is at first controllable. As the condition advances these 
early symptoms become more manifest. The skin becomes 



DELIRIUM TREMENS. 749 

flabby, the face may show venous congestion, and acne rosacea 
may show itself upon or about the nose. Symptoms of gastric 
catarrh are present. There may be injection of the conjunctiva, 
and perspiration occurs upon slight exertion. The tongue is 
flabby and furred, the tremor being marked when it is pro- 
truded. Leukoplakia may occur, especially in males. The 
breath is fetid and has a peculiar odor. There is frequently 
great thirst. There is often disgust for food, especially in the 
morning, which is made worse by the early morning nausea 
and vomiting. In severe cases the retching may cause 
hematemesis. In beer drinkers gastrectasis frequently occurs. 
Insomnia is an early and almost constant symptom ; and if 
the patient sleeps at all, he is disturbed by bad dreams and 
nightmares. Peripheral neuritis may develop, first appearing 
as tenderness in the legs, which may be succeeded by sen- 
sations of pain, by wasting, and by paralysis of the muscles, 
affecting principally the extensors of the feet, so that foot- 
drop and loss of knee-jerks may result. The will and the 
intellectual faculties are greatly impaired ; there is marked 
perversion of the moral tendencies, leading to falsehoods and 
deceit. The resistance of the body becomes lessened, so that 
when drinkers are attacked by acute disease, — as, for instance, 
croupous pneumonia, — they readily succumb. 

Prognosis. — The prognosis is unfavorable. 

Treatment. — The treatment consists in endeavoring to 
remove the cause. Such patients are best treated in an insti- 
tution. Sleeplessness should be controlled by sedatives, 
although great care should be taken in using such drugs as 
morphin and chloral. It is better to rely upon trional, the 
bromids, and the hypodermic use of hyoscin. The general 
nutrition of the body must be looked after. Proper hygiene, 
— such as exercise in the open air, — bathing, massage, and 
so on, are of value. Many drugs have been recommended 
as specifics, but no one drug or method has been found suc- 
cessful. 

DELIRIUM TREMENS* 

Synonyms. — Alcoholic delirium ; mania-a-potu ; the hor- 
rors. 

This may follow a single attack of hard drinking, but it 
occurs much more commonly in chronic alcoholism. It is 
most liable to affect persons who drink constantly without 
ever suffering from acute intoxication. Hereditary influences, 



750 INTOXICATIONS AND SUNSTROKE. 

such as insanity, various neuroses, and alcoholism predispose 
to delirium tremens. The attack may occur in drinkers after 
trauma, after shock, or during the course of an acute infectious 
disease, such as croupous pneumonia. It occurs after surgical 
operations in alcoholics. 

Symptoms. — The prodromes consist of nervousness, rest- 
lessness, and anorexia. There is insomnia ; or if sleep occur, 
it is disturbed by bad dreams. The onset of the attack is 
marked by an aggravation of the prodromal symptoms. 
A tremor especially affects the lips, tongue, and limbs. 
Delirium soon develops, which is active and constantly chang- 
ing. The patient experiences a sensation of uneasiness and 
has a desire to be in continual motion. The skin is wet, being 
bathed in perspiration. The expression is anxious. The 
pupils are dilated. The excitement is caused by fear due to the 
delusions and by aural and visual hallucinations ; these are very 
frequently terrifying, the patient imagining he sees or hears 
serpents, insects, and dragons, which seem to come toward him. 
He may cease to recognize his attendants, and becomes suspi- 
cious ; and while laboring under a hallucination he may attack 
his attendants. Frequently the patient may be controlled and 
humored by those understanding the condition. The temper- 
ature is subfebrile, rarely going above 103 ° F. The pulse is soft 
and rapid. The tongue is covered by a thick fur. There is 
complete insomnia. The disease is self-limited, lasting from 
two to four days. At the end of the period the patient falls 
into a quiet and peaceful sleep, and upon awakening is free 
from delerium ; the tremor, however, persists for some time. 
In favorable cases convalescence is rapid. If there have been 
several previous attacks, hyperpyrexia may occur, which may 
prove fatal, or the patient may die from some complicating 
disease, particularly croupous pneumonia. 

Prognosis. — In the first attack the prognosis is generally 
favorable. Old age, previous -attacks, and complications are 
unfavorable prognostic signs. 

Treatment. — Probably the most important feature of the 
treatment is careful feeding. The patient, as a rule, is half 
starved, and will show great unwillingness and reluctance to 
taking food. If necessary, a nasal tube should be used to 
administer food. For this purpose concentrated foods are best. 
But little food should be given at a time, but it should be fre- 
quently administered. Vomiting should be relieved by small 
pieces of ice and small quantities of effervescent mineral waters. 



METAL POISONING PHOSPHORUS. 75 I 

If vomiting be persistent, rectal alimentation must be resorted 
to. If there are signs of heart failure, stimulants must be 
administered. Strychnin hypodermically is of great value. A 
purge by calomel at the onset is often of benefit. Every effort 
should be made to induce sleep ; the most useful agents are 
morphin hypodermically or hyoscin. Choral is also useful, 
but it has a depressing effect upon the heart. Complications 
must be treated as they arise. 



METAL POISONING. 

PHOSPHORUS. 

Poisoning occurs in workmen occupied in the manufacture of 
matches ; phosphorus is rarely used for suicidal purposes. Poi- 
soning may be either acute or chronic ; the chronic form is espec- 
ially met with in those occupied in the handling of phosphorus 
for manufacturing purposes. 

Symptoms. — Symptoms from a toxic process occur in from 
one to six hours after the drug has been swallowed. The 
poison has a disagreeable taste and smell, and pain soon de- 
velops in the region of the esophagus .and stomach, this 
being followed by vomiting. The mucous membrane of 
the mouth and throat is dry and swollen. The vomited 
matter is often tinged with blood, and may be luminous 
in the dark and have the characteristic odor of phosphorus. 
The vomiting continues for several days, accompanied by 
diarrhea, insomnia, and great pain in the esophagus. The 
pulse- and temperature are usually normal. About the third 
or fifth day jaundice appears, accompanied with the vomit- 
ing of coffee-ground material. The pulse-rate becomes 
slower, and, if the case be unfavorable, the pulse-rate in- 
creases ; tachycardia may be a symptom. If fever sets in, 
it is an unfavorable sign. Marked changes take place in the 
liver, which is at first enlarged, but rapidly becomes atrophied. 
The urine is scanty, albuminous, loaded with biliary salts, and 
often contains crystals of leucin and tyrosin. Delirium and 
convulsions may now occur, giving place to coma. A fatal 
issue takes place in about 40^ of the cases of acute phos- 
phorus-poisoning. 

Treatment. — Efforts should be rnade^ to prevent the ab- 
sorption of the toxic agent, emetics and purgatives being 



75 2 INTOXICATIONS AND SUNSTROKE. 

promptly administered. Sulphate of copper may be given as 
an emetic and lavage should be constantly used until the wash- 
ings no longer have the odor of phosphorus. No fatty food 
should be given, not even milk or eggs, as fat dissolves phos- 
phorus. Potassium permanganate, well diluted, is a good 
oxidizing agent, and should be administered early. The 
usual antidote is oil of turpentine. The bowels should be 
moved by salines or by enemas. 

CHRONIC PHOSPHORUS-POISONING. 

This occurs particularly in those engaged in the manufacture 
of matches, and the condition has been termed phosphorism. 
There soon develop a cachexia, showing a yellowish tint of 
the skin, the exhalation of a garlicky odor by the breath, 
with marked anemia, the occurrence of cystitis, bronchitis, 
and a necrosis of the jaw-bone, and the presence of phosphorus 
in the urine and saliva. 

Treatment. — In the treatment of this condition a milk diet 
should be given. Moderate exercise, inhalation of oxygen, 
and repeated small doses of turpentine are of value. If a 
periostitis of the jaw-bone occurs, free incision with thorough 
drainage should be practised. 

COAI^GAS AND WATER-GAS POISONING* 

Illuminating gas owes its poisonous properties to carbon 
monoxid, which it contains from 5 % to 10^ of its amount. 
In water-gas the amount possessed reaches from 30^ to 40^. 
This gas is often used for suicidal purposes, and the toxic 
effects vary with the amount of carbonic oxid inhaled. At 
first there may be only general feelings of discomfort, with 
throbbing of the vessels, marked headache, vertigo, and great 
debility, which is soon followed by nausea and vomiting. 
Drowsy sensations rapidly ensue, which terminate in coma, 
occasionally with delirium and convulsions. The skin becomes 
dusky, the lips and extremities are cyanotic, the pulse is full 
and bounding, and the respirations are labored. The patient 
dies asphyxiated. If convalescence occur, pulmonary and ner- 
vous complications may appear. 

Treatment. — The patient should be removed from the in- 
fluence of the poison as quickly as possible, artificial respira- 
tion being resorted to. Inhalations of oxygen and hypodermics 



CHRONIC LEAD-POISONING. 753 

of strychnin are useful, but in all grave cases venesection and 
transfusion should be resorted to. 



CHRONIC LEAD-POISONING* 

Synonym. — Plumbism. 

Etiology. — This condition occurs most often in workmen 
who are exposed in their occupations, by frequently or con- 
stantly coming in contact with lead or its compounds. It 
may, however, develop from the accidental absorption, fre- 
quently repeated, of small quantities of the metal. Lead may 
reach the system by the digestive tract or may be absorbed 
through the respiratory tract, skin, or mucous membranes. 
The compounds of lead, such as its salts or its alloys, may 
produce toxic phenomena ; especially is this true of the form 
known as white lead, in which case the symptoms come on 
rapidly and. are characterized by marked .severity, vlen are 
more frequently affected than women on account of greater 
liability to exposure. Children appear to be more susceptible 
than adults. Painters are frequently affected by lead-poison- 
ing, as are also glass grinders, glaziers, and workmen en- 
gaged in the filling of storage batteries. Lead-poisoning may 
occur from drinking water which has become contaminated by 
flowing through leaden pipes or by being stored in cisterns. 
It may occur from biting colored threads which are stained 
with lead. Occasionally it is impossible to determine the 
source of the poison. 

Pathology. — Changes are found in the peripheral nerves. 
The nerve-endings show a neuritis ; even in the nerve-trunks 
degeneration may occur in patches, which is, however, more 
commonly marked toward the periphery, lessening in extent 
in the neighborhood of the cord. From this cause the mus- 
cles undergo atrophy. In cases of lead encephalopathy the 
vessels of the brain show arteriosclerotic changes, which may 
lead to softening, and hemorrhages following. Postmortem, 
lead has been found in the liver, kidneys, brain, and bone- 
marrow. The kidneys show the changes common to inter- 
stitial nephritis. The liver may show a similar change. It is 
probable that parenchymatous alterations precede the inter- 
stitial changes in the kidney. 

Symptoms. — The symptoms presented by lead-poisoning 
show varying grades. As a rule, there are disturbance of 
nutrition, loss of flesh, anemia, arthritic pains, headache, and 



754 INTOXICATIONS AND SUNSTROKE. 

general malaise. An important symptom is the blue line 
upon the gums, which is situated at the junction of the gum 
with the teeth in both the upper and the lower jaws. Occa- 
sionally the line is of a deep blue color. If the teeth are clean 
and free from tartar, the line may be entirely absent, or it 
may be present for a long time without marked symptoms of 
plumbism. It is due to the deposit of the sulphate of lead, 
which is formed by the combination of lead circulating in the 
blood with sulphureted hydrogen due to the decomposition 
of the tartar upon the teeth ; thus, the line may appear very 
rapidly. It has been seen within twenty -four hours in persons 
after having used salts of lead for medicinal purposes. With 
this blue line the gums are frequently swollen and spongy. 
The breath is fetid. There is a metallic taste in the mouth and 
the tongue shows marked coating. Some grade of anemia is 
always present, although in the majority of cases it is of but 
moderate extent and of the chlorotic type. The erythrocytes 
are rarely less than 3,000,000 ; the hemoglobin, however, may 
be considerably diminished. The gastro-intestinal symptoms 
are of great importance. Lead colic is one of the characteris- 
tic phenomena of the affection. There is violent pain in the 
abdomen, which either may begin suddenly or may be pre- 
ceded by slight pains for a day or two. There is marked tenes- 
mus both of the bladder and rectum. There may be reten- 
tion of urine, and even strangury. Obstinate constipation is 
the rule. Very rarely diarrhea is present. Often there are 
nausea and marked vomiting. When the vomiting is long 
continued, it has a biliary character. In lead colic the pulse 
becomes full and bounding ; it is the high tension pulse. 
The rapidity of the pulse is lessened. Bradycardia may occur, 
and the pulse may be as low as 30 or 40 a minute ; it is, how- 
ever, regular in rhythm. As a rule, the respirations are in- 
creased in frequency. The amount of urine is diminished, 
and the entire attack may last a week. Relapses are very 
common, especially upon renewed exposure. Paralysis is a 
common symptom, affecting particularly the extensor mus- 
cles of the forearm, producing wrist-drop. As a rule, both 
arms are affected, although one may show the condition to a 
greater extent than the other. The paralysis often comes on 
suddenly, becoming well marked in from two days to a week. 
Other muscles besides the extensors may be affected. Occa- 
sionally the deltoid, the biceps, and the brachialis anticus are 
affected, but most commonly the biceps and the pectoral mus- 



LEAD ENCEPHALOPATHY. 755 

cles are implicated. When the small muscles of the hand be- 
come affected, atrophy of the thenar and hypothenar eminences 
appear most markedly, these being the earliest muscle groups 
involved. Paralysis of the legs is rare. Tactile sense is at 
first not implicated. Occasionally there is slightly diminished 
tactile sense, with some numbness in the affected muscles ; 
however, pains in the joints are common. This condition 
has been called saturnine arthralgia. Blindness and convul- 
sions are sometimes symptoms. 

LEAD ENCEPHALOPATHY. 

This condition is not common in lead-poisoning and occurs 
only in those who have become poisoned by large quantities 
of lead. 

The symptoms consist in convulsions, delirium, and coma. 
As a rule, it takes from several months to a year to develop 
these symptoms, and a preceding history of colic, paralysis, 
and arthralgia is often obtained. Marked anemia and cachexia 
develop with vomiting and headache. There may be distur- 
bance of vision, vertigo, tremor, insomnia, restlessness, mental 
depression, and more rarely hallucinations and delusions. 
Convulsions are the most common of the nervous symptoms 
which develop in severe cases. As a rule, there are repeated 
seizures, and they are characterized by the development of 
coma in the interval, in which the Cheyne-Stokes respiration 
may occur. This may be followed by the development of 
edema of the lungs, with hyperpyrexia, which may precede the 
fatal issue. 

In the forms characterized by nervous phenomena the 
blue line upon the gums is a most important diagnostic symp- 
tom. Ocular phenomena occur, the most common being 
neuroretinitis. Primary optic atrophy, which may be advanced 
to complete blindness, has also been noticed in some cases. 
Young females affected by lead-poisoning are apt to develop 
amenorrhea and menorrhagia, and pregnant women commonly 
abort. The offspring of such parents are apt to suffer from 
convulsions early in life, which in the majority of cases are 
fatal. 

Complications. — The common complications are those 
relating to the heart and kidneys. Hypertrophy of the left 
ventricle and interstitial nephritis develop in protracted cases. 
Gout has also been observed as a complication. 



756 INTOXICATIONS AND SUNSTROKE. 

Diagnosis. — The diagnosis depends largely upon the his- 
tory of exposure, the blue line upon the gums, lead colic, and 
paralysis of the extensors. 

Prognosis. — Recovery often takes place from the most 
severe forms of lead-poisoning. Development of cerebral 
symptoms adds considerably to the gravity of the case. Com- 
plications relating to the heart and kidneys are permanent and 
progressive. 

Treatment. — Efforts should be made to remove the patient 
from the influence of the toxic agent. The elimination of lead 
takes place through the urine and the feces. Lemonade, 
to which a few drops of sulphuric acid are added, followed 
by a dose of sulphate of magnesium may be found efficient 
in many cases. The usual treatment consists in the adminis- 
tration of iodid of potassium. For the lead colic opium in 
some form, preferably morphin hypodermically, is advocated. 
Constipation may be relieved by enemas of soap and turpen- 
tine. Atropin combined with morphin is of use in relaxing 
the intestinal spasm. When general paralysis occurs, strychnin 
is a valuable drug. Galvanism should be employed to keep 
up the nutrition of the muscles, and for the anemia iron in some 
form is the most useful drug. 

CHRONIC MERCURIAL POISONING. 

Synonym . — Pty alism . 

Etiology. — This condition has become comparatively rare 
owing to improved hygiene among the working-people. The 
disease is met with in quicksilver mines where the ore is heated. 
Mirror gilders, thermometer makers, hatters, and furriers who 
use the salts of mercury are apt to manifest the toxic effects 
of mercury. It sometimes arises from the internal adminis- 
tration of mercury. Some persons show a marked tendency 
or susceptibility to the drug, even to minute doses of calo- 
mel. 

Pathology. — In cases of acute poisoning an intense inflam- 
mation of the gastro-intestinal tract is produced. Acute in- 
flammation of the kidney is liable to occur in these cases. 
The peripheral nerves are sometimes affected, owing to the de- 
generation of the sheath, whereas the axis-cylinders remain 
intact. 

Symptoms. — The symptoms are those of mercurial stoma- 
titis described in the previous section. (See p. 437.) 



CHRONIC ARSENICAL POISONING. 757 

CHRONIC ARSENICAL POISONING. 

This may arise from the inhalation of arsenic in wall-paper, 
through certain molds which have the power of liberating 
arsenic in the form of a vapor, this condition being favored by 
moisture ; hence it is liable to occur in damp weather. Arsenic 
is frequently present in the coloring-matter of various artificial 
flowers and hangings, dark-red cotton papers, labels, papers 
used in kindergartens, etc. It is used by the taxidermist in 
stuffing birds and various animals. From the internal admin- 
istration of arsenic slight toxic effects are produced, and cases 
of peripheral neuritis due to this cause have been described. 

Pathology. — The peripheral nerves show degenerations 
similar to those occurring from lead. Fatty degeneration of 
the liver-cells has been noted with infiltration of leukocytes. 

Symptoms. — In chronic poisoning from arsenic catarrhal 
symptoms, particularly of the gastro-intestinal tract, occur. 
Symptoms referable to the nervous system and skin are also 
prominent. The most characteristic of these symptoms are 
* those of the nervous system, and are due to the extensive 
neuritis, closely resembling that form due to alcohol and lead, 
which, as a rule, begins in the lower extremities with sensory 
phenomena. There are numbness and tingling, and hyperes- 
thesia, paresthesia, and later anesthesia in the nerve-trunks and 
muscles. Paralysis occurs, particularly affecting the lower 
extremity. There is loss of knee-jerk, which is an early and 
almost constant symptom. Rapid atrophy occurs in the mus- 
cles, which present reactions of degeneration. As a rule, the 
sphincters of the bladder and rectum are not affected. Among 
the gastro-intestinal symptoms are nausea, vomiting, coated 
tongue, with a metallic taste in the mouth, and severe epigas- 
tric pain. Coryza occasionally occurs, and hematuria has 
been noted in some cases. Various eruptions upon the face 
occur, particularly urticaria, and herpes zoster has also been 
noted. Pigmentation of the skin is common and persistent. 
Anemia of the chlorotic type occurs. 

Prognosis. — As a rule, even the severe forms of paralysis 
are amenable to treatment, although the affection is a chronic 
one. 

Treatment. — The cause should, if possible, be removed. 
Iodid of potassium is indicated. Neuritis should be treated as 
in other forms of poisoning, by electricity, massage, strychnin, 
and tonics. 



75^ INTOXICATIONS AND SUNSTROKE. 

CHRONIC SILVER POISONING. 

Synonym. — Argyria. 

This condition is most frequently due to the long-continued 
use of the silver salts as a drug. Silver is deposited in the 
tissues, where it is recognized under the microscope as small 
black particles of metallic silver. This is best seen in the skin 
and in the kidneys. The discoloration of the skin is marked, 
often of a deep blue color, later not unlike intense cyanosis. 
The mucous membrane and the teeth are also discolored. A 
black line is often present on the gums. Parenchymatous 
changes occur in the liver and kidneys. (See p. 32.) 



SUNSTROKE. 

Definition. — Sunstroke is a disease characterized by pros- 
tration, with high fever, followed by coma ; and is due to 
exposure to the rays of the sun. 

Synonyms. — Heat stroke ; thermic fever. 

Etiology. — The disease occurs most frequently in hot 
climates in which the humidity is high. Alcoholism is a 
marked predisposing cause. It results from exposure and 
exertion in the sun. Elderly persons with chronic ailments, 
are liable to have an attack of sunstroke. Absence of drink- 
ing-water is said to be a predisposing cause with soldiers upon 
the march. The white race is more liable to be affected than 
the negro race. 

Pathology. —The brain and its membranes, the lungs, and 
some of the abdominal viscera often reveal marked conges- 
tion. The vena cava and the right auricle are often distended 
with partially coagulated blood, which is dark red in color, 
almost black. Granular degeneration of the ganglion cells 
of the brain and spinal cord has been observed, and in some 
way seems to have a relationship to the symptoms. Paren- 
chymatous degeneration is also observed in the liver and kid- 
neys. Polycythemia may exist, which is probably due to 
blood concentration. If recovery occur, anemia develops, 
showing probably that hemolysis has been pronounced. The 
leukocytes are increased in number, and some of them may 
contain blood-pigments. 

Symptoms. — As a rule, prodromes occur, which may be 
present for a few hours or several days before the attack 



HEAT EXHAUSTION. 759 

shows itself. On the other hand, the attack may begin sud- 
denly. The premonitory symptoms usually are restlessness, 
sleeplessness, rapid shallow breathing, precordial distress, 
nausea, and sometimes vomiting, thirst, frequent micturition, 
and some rise in temperature. These symptoms gradually 
increase in severity, and the temperature reaches from 106 
F. to 1 1 5° F., and is often higher. Dyspnea is marked, and 
the skin of the entire body is red and sometimes livid ; it 
is most often dry, but occasionally some moisture is noted. 
The pulse is full and bounding and the pupils are contracted. 
Cheyne-Stokes respiration is noted as unconsciousness passes 
into complete coma. Convulsions may occur, and in individ- 
ual cases the pupils may dilate. There is relaxation of the 
sphincters preceding death. 

HEAT EXHAUSTION* 

This is a condition characterized by prostration and normal 
or subnormal temperature, due to exposure to excessive heat. 
It is commonly met with in the working-classes, as firemen 
of ocean steamers, bakers, and laundry workers. The disease 
is commonly encountered in alcoholics, also in individuals 
who wear unsuitable clothing. It is more frequent among 
males than females. 

Symptoms. — In heat exhaustion, as a rule, premonitory 
symptoms occur which consist in uneasiness in the epigas- 
trium, dizziness, headache, irregular pains in the extremities, 
and occasionally tingling. Often there are nausea and vomit- 
ing. The prostrationg radually increases and the headache 
becomes marked. The patient appears dazed, and sensations 
are but partially perceived. The respirations are slightly in- 
creased, however ; the pulse becomes rapid, — from 130 to 140 ; 
the temperature may be normal or subnormal ; occasionally 
some slight fever is noted. As a rule, the patients recover. 

Complications. — Insanity and meningitis may be compli- 
cations. Occasionally pneumonia develops, and persons with 
renal disease develop uremic attacks. Cerebral hemorrhage 
has been known to follow sunstroke. The sequels consist in 
headache which may last for a long time, vertigo, general 
muscular soreness, and tingling in the extremities, this some- 
times lasting for weeks or months. Anemia, as a rule, is 
marked. Epilepsy has followed cases of sunstroke. Persons 



760 INTOXICATIONS AND SUNSTROKE. 

who have had an attack are extremely liable to second attacks 
upon exposure. 

Prognosis. — In those cases of heat exhaustion that come 
under treatment early the prognosis is good. In sunstroke 
when the temperature reaches 110 F. or 11 2° F. and over, 
if properly treated, about half of the cases recover. The 
prognosis is less favorable in alcoholics and in persons subject 
to chronic disease of the heart, lungs, or kidneys. 

Treatment. — The treatment of thermic fever consists in 
the application of cold to the surface of the body, preferably 
in the form of an ice-bath or ice rubbing. The cold pack is 
sometimes substituted. The bath is commonly continued 
until the temperature reaches the normal point. Ice-water 
enemas may also be employed. 

In heat exhaustion the patient should be placed in a warm 
bath, and stimulants, such as ammonia, strychnin, whisky, 
ether, and nitroglycerin, administered. For the anemia that 
follows iron and arsenic are indicated. Antipyretics, such as 
antipyrin, may be employed, particularly in those cases in 
which a cold bath can not be given. 



PART XL 
DISEASES DUE TO ANIMAL PARASITES. 



PROTOZOA. 

The amoeba coli belongs to the order of protozoa. It 
varies between 20 and 30 fi in diameter. The organism con- 
sists of hyaline protoplasm, the cell-wall not being discernible. 
In the protoplasm there are vacuoles which may vary in size. 
The protoplasm occasionally contains foreign matter, such as 
bacteria, starch globules, and blood-cells. It possesses con- 
tractility, pseudopods being thrown out when the organism 
is in motion ; therefore, the parasite is globular, oval, or irreg- 
ular. 

The parasite is best studied by taking a specimen from a 
stool that has just been passed, and the examination had better 
be conducted upon a warm stage. It is most often found in 
masses of bloody mucus. The amoeba coli stains faintly with 
the basic aniline dyes, and can be well studied in the stained 
specimens when treated with toluidin-blue (as recommended 
by Harris). 

The discovery of this parasite was made by Losch, in the 
year 1874, in St. Petersburg. The amoeba coli is associated 
with tropical dysentery ; it is found in the stools, in the coats of 
the bowel, also in tropical abscesses of the liver, and rarely in 
other parts. A few observers believe that it does not possess 
pathogenic properties. (For description of Amebic Dysentery, 
see p. 298.) 

Hematozoa of Malaria. — (See p. 198.) 

Psorospermosis. — Psorosperms, or coccidia, which are fre- 
quent in the lower animals, occasionally occur in the human 
subject. When affecting man, the disease is at first local, later 
it shows a tendency to invade the system, becoming diffused 

761 



j62 DISEASES DUE TO ANIMAL PARASITES. 

in different parts of the body, and sometimes causing death. 
The psorosperm attacks particularly the epithelial cells of the 
mucous membranes and of the skin, extending into the sur- 
rounding tissue, in this manner entering the lymph- or blood- 
vessels. 

Pathology. — The disease produced by the coccidium ovi- 
forme has been particularly studied in the rabbit. It affects 
the liver especially, numerous minute firm nodules being 
found in the organ. The nodules vary in size, and may 
attain a diameter of about ^ of an inch. They contain a 
central, caseous mass, which can readily be expressed or sepa- 
rated. The coccidia measure from 26 to 28 fi in length, and 
from 13 to 14 fi in breadth. They are found in three stages, 
according to the degree of development. In the least mature 
the contents are generally granular. A further stage of de- 
velopment shows the granular material gathered to a central 
spheric mass, and in the fully developed form the granular 
mass divides into four psorosperms or spores. These are 
ready to undergo further development under suitable con- 
ditions. The parasite belongs to the order protozoa ; sub- 
division, coccidiidea. 

The disease has been observed in man both as a local and 
as a general condition. Locally, it has been met with in the 
liver, producing conditions similar to those observed in the 
rabbit. 

The symptoms observed are progressive wasting, nausea, 
and exhaustion, followed by a fatal issue. 

If the parasite affects the urinary passages, increased fre- 
quency of micturition with hematuria takes place ; small super- 
ficial cysts with clear contents are passed. It may block the 
urinary passages, and so cause hydronephrosis. It may at- 
tack the intestinal mucous membrane, giving rise to con- 
stant diarrhea, hemorrhage, exhaustion, and general dyspeptic 
symptoms. 

As a general disease, there are few characteristic symp- 
toms. There are pains in the limbs, headache, drowsiness, 
delirium, dry furred tongue, nausea, vomiting, albuminuria, 
fever of a remittent type (rarely above 103 F.), and in- 
creased size of the liver and spleen. Symptoms of the 
" typhoid state " intervene. Death takes place in from two 
to seven weeks. 

Cercomonas_ and trichomonas intestinalis are found in the 
intestines and stools ; they probably do not produce disease. 



WORMS. 763 



WORMS. 

Worms are divisible into various classes ; only two, how- 
ever, occurring in man. These are (1) the Platyelminthes, or 
flat-worms, which have flat, elongated bodies ; the heads are 
provided with hooklets or suckers or both, possessing a 
cerebral ganglion, and, as a rule, being hermaphroditic ; 
(2) the Nematlielmintlies, or round-worms, may be defined 
as having tubular bodies. The end representing the head 
is provided with hooks or papillae ; the sexes are distinct. 

FLAT-WORMS. 

(a) Cestodes. — The cestodes, or tapeworms, are long, rib- 
bon-like, flat, whitish organisms, which when matured inhabit 
the alimentary canal of many of the vertebrate animals. 

The worm may be divided into a head, a neck, and a num- 
ber of segments. The head has from two to four discs, some- 
times called suckers, and in some of the varieties these are 
arranged around a rostellum, and occasionally there are 
hooklets. These hooklets help to hold the parasite in the 
intestine of the host. The head is very small, and in the ma- 
jority of cases can just be distinguished with the naked eye. 
It shows itself as a small bulbar point at the end of the nar- 
rowest point of the worm ; this is joined to the series of seg- 
ments known as the proglottides. Segments gradually increase 
in size until they become more mature. The matured pro- 
glottides possess male and female organs of reproduction, 
the latter containing the eggs. As the ova mature the pro- 
glottides containing them break off and pass out of the body 
of the host by their own movements or with the feces. In a 
few species the ovum at birth is undeveloped, but, as a rule, 
the embryo is covered by a shell. The embryo, in most 
instances, possesses about five or six 'hooklets. As it arrives 
in its intermediate host (ox, pig, fish, etc.), the shell in which 
it is. contained is dissolved and it bores its way through the 
walls of the intestine and the intervening tissues until it finds 
lodgment in the muscles, liver, lungs, or some other tissue. 
The hooklets are now cast off and a head and neck, which 
conform to the type of the tapeworm in general, are developed. 
The scolex, or larval form is contained in a clear, Avatery 
bladder, which is called the cysticercus. In some forms of 
tapeworm this cyst is very small and rudimentary. 



764 DISEASES DUE TO ANIMAL PARASITES. 

In another variety (taenia echinococcus) the cyst formation 
becomes extensive, and from a process of development of the 
inner cellular layer of the wall of the cyst a number of smaller 
capsules are formed. In the fourth variety there is no cyst ; 
the embryo enlarges, the head and two grooves being formed 
at the end ; these are known as the bothriocephalidae. 

Many worms retain their power of development for a long 
period, sometimes years ; others soon die and become calcified. 

The tapeworms, of cestodes, in man are represented by two 
families — the tceniadce and the bothriocephalidce. The taeniadae 
have four suckers, and some have a single or double row of 
hooklets placed upon a rostellum ; the bothriocephalidae have 
only two suckers, as a rule. 

In man but three species of fully developed tapeworm com- 
monly occur — the taenia saginata or mediocanellata, or beef 
tapeworm ; the taenia solium, or pork tapeworm ; and the 
bothriocephalus latus, or fish tapeworm. Some other varieties 
are occasionally met with, but they are rare. The taenia echino- 
coccus in its larval state occurs in man. 

Taenia Saginata, or Beef Tapeworm. — The head is sur- 
mounted by four suckers, with a rudimentary sucker in its 
center. The segments measure from 8 to 10 mm. in breadth 
and about 18 mm. in length. At the sides of the proglottis 
are placed the genital pores. The length of the worm varies 
from 4 to 10 meters. The ova are oval and measure about 
0.03 mm. in their longest diameter. Hooklets probably can 
not be seen in the embryo ; however, some observers hold that 
they do exist and can be demonstrated. 

Taenia solium, or pork tapeworm, is sometimes called the 
armed tapeworm because the rostellum is supplied with two 
rows of hooklets, each row containing from 12 to 14 hooklets. 
The head is quadrilateral, also being supplied with four suc- 
torial discs. The worm measures about 4 meters in length. 
The segments measure from 6 to 8 mm. in breadth and from 10 
to 12 mm. in length. Behind the middle of the proglottis are 
found the genital pores, the uterus being less branching than in 
the taenia saginata. The ova are about the size of those of the 
beef tapeworm. The embryo is supplied with hooklets. 

Bothriocephalus Latus, or Taenia Lata. — The length of 
the worm varies from 5 to 16 meters. The head is elongated 
and supplied with two grooved suckers, one on each side. The 
breadth (1.8 cm.) of the joints is greater than the length. 
The mature segments show a rosette arrangement of the 



WORMS. 765 

uterus which is quite characteristic. The eggs are oval, 
measuring about 0.07 mm. in the longest diameter. 

Symptoms Produced by Tapeworms. — The tapeworm may 
attain considerable size, and may infest the host for a long 
period of time without giving rise to symptoms. The. diag- 
nosis of tapeworm in such cases can be made positive only by 
finding segments. As a rule, the appetite is good ; often there 
are colicky pains and alternating diarrhea and constipation. 
There may be dyspeptic symptoms with nausea, especially 
when the stomach is empty. There may be anemia, and, as a 
result of the presence of the bothriocephalus latus, extreme 
anemia has often been observed. Occasionally there are nervous 
symptoms, such as vertigo, chorea, and epileptic seizures. All 
symptoms are apt to become aggravated when the stomach is 
empty. It is said that the symptoms are more severe from 
the bothriocephalus latus on account of its larger size. 

Treatment. — The most reliable anthelmintics are the male 
fern ; the pomegranate root bark, and its alkaloid, pelletierin ; 
kousso ; pumpkin seeds ; turpentine, and chloroform. Thymol 
is also highly recommended by some authorities. Filix mas 
is a very reliable vermifuge. Before the administration of any 
of these drugs the patient should be put upon a milk diet for 
at least twenty-four hours ; it is then desirable the night before 
the vermifuge is administered to give a brisk cathartic, pre- 
ferably calomel. Early the following morning the anthelmintic 
is administered, and a few hours afterward another purgative. 
It is always necessary to search for the head, and it must be 
remembered that if the head does not pass, the worm will 
rapidly reform. Occasionally two or more worms may infest 
the same host, but if no symptoms appear for three months 
after the worm has been passed, a cure may be considered to 
have been effected. 

Taenia Echinococcus. — Synonym. — Hydatid worms. 

It is a small parasite, from 4 to 5 mm. in length, and about 
0.6 mm. in breadth, and is composed of five segments, the 
terminal one being the largest. It is an exceedingly rare para- 
site, and is found in the intestine of the wolf and the dog. 
The head is supplied with 4 suckers and about 24 hooklets, 
situated upon a rostellum in a double row. The ripe seg- 
ment contains about 5000 eggs, which further develop in many 
organs, particularly in those of the hog and the ox, more rarely 
in the sheep and the horse. In some climates man may be 
the host from accidental ingestion of the ova. 



J66 DISEASES DUE TO ANIMAL PARASITES. 

The embryo has six hooklets, and when liberated from its 
shell, it works its way through the intestinal wall into the 
organs. Commonly it enters the portal vein, lodging in the 
liver ; it then may find its way into the hepatic veins, passing 
to the lungs, and sometimes by way of the pulmonary vessels 
to the left side of the heart, and reaching other organs. 

When it becomes embedded, a small cyst forms. The cyst 
contains a clear fluid and the cyst-wall consists of two layers 
— the external capsule, which is laminated, and the internal, 
granular or parenchymatous layer, known as the endocyst. 
Chronic inflammatory reaction appears in the surrounding 
tissues, and in a short time fibrous tissue forms. 

In the growth of the cyst buds develop from the internal 
layer, which are also converted into cysts, being identical with 
the original one. These are called secondary or daughter, 
cysts. At first they are connected with the primary cyst, but 
later are set free. In this way, from the primary cyst a dozen 
or more daughter cysts may develop. A similar process 
goes on in the daughter cysts. From the lining membrane 
growths develop, known as scolices, which are actually the 
head of the tapeworm (the taenia echinococcus), presenting a 
circle of hooklets and four sucking discs. Each head when 
entering the intestine of the dog is capable of developing into 
an adult tapeworm. 

The fluid of the echinococcus cyst is clear and limpid, and 
has a specific gravity of from 1005 to 1009. Traces of sugar 
are present, but no albumin. The fluid of the cyst contains 
the characteristic hooklets, except when degenerative changes 
have taken place. 

The embryo form of the echinococcus may remain alive for 
many years. When death takes place, it occurs from a 
granular change or calcification of the cyst. If the cyst 
ruptures, perforation may take place internally or externally. 
Occasionally even recovery may follow rupture. Rarely sup- 
puration appears, large abscesses having been found that were 
due to hydatids. Hydatid disease is common in Australia and 
in Iceland ; it is rare in Europe and America. The most com- 
mon seat of the cysts is in the liver, as about 45 °fo of all the 
cysts are found in this organ ; the next most frequent seat is 
in the lung or pleura. 

Symptoms. — Only large cystic formations give rise to symp- 
toms. The physical signs, of course, will depend upon the sit- 
uation of the growth. They will be those of a tumor, at times 



WORMS. 767 

firm, rarely with fluctuation. Frequently a tumor may be 
noticed to the left of the suspensory ligament of the liver, 
pushing up the heart and giving quite an extensive area of 
dullness upon percussion. If the cyst be superficial, it may 
give rise to a condition known as hydatid fremitus or hydatid 
thrill. This is elicited by palpating lightly with the fingers 
of one hand, percussing at the same time with those of the 
other ; a vibration or trembling in the mass being the result, 
which may last for some time. With suppuration, symptoms 
of pyemia will develop. Occasionally from the rupture of 
a hydatid cyst urticaria develops. This sometimes follows 
aspiration. 

Diagnosis. — This depends chiefly upon the finding of the 
hooklets in the fluid from the cyst. 

Treatment. — Operative measures should be resorted to if 
the cyst becomes large or gives rise to pressure symptoms. 
Simple aspiration is all that is necessary in quite a number of 
cases. Injections into the sac are useless. 

(b) Trematodes. — These are flat, leaf-shaped, unsegmented 
worms, possessing a mouth and a pharynx. They are most often 
hermaphrodites. In some few species the sexes are separate. 

The trematodes which occur in man belong to the family 
distomidae. 

Distomidse. — Those that occur in man are oviparous. The 
ovum at birth contains a ciliated embryo. On leaving the 
uterus of its parent it is carried in the discharges of the host 
into water or muddy soil ; here the embryo is hatched out, 
and for a short period swims around and searches for its 
special intermediate host. This is most often a mollusc or 
crustacean. 

Several forms of distoma are found in man, the most com- 
mon being those found in the liver, known as liver flukes ; those 
occurring in the blood, known as blood flukes (bilharzia haem- 
atobia) ; and the form found in the bronchial tubes, known as 
the bronchial flukes, or ringeri. In the liver two or three 
varieties of the distoma have been found — the distoma 
hepaticum, which attains a length of from 28 to 32 mm. ; the 
distoma lanceolatum, being much smaller, from 8 to 10 mm. 

There is a certain distoma which is endemic in some parts 
of Japan. According to some authorities 20^ of the inhabi- 
tants of certain provinces in Japan are affected by this parasite. 
The parasite occupies the upper portion of the small intestine 
and the biliary passages. When present in large numbers, 



76% DISEASES DUE TO ANIMAL PARASITES. 

an exceedingly fatal disease of the liver is produced, accom- 
panied by ascites and jaundice, in which the liver enlarges 
enormously. 

The bilharzia haematobia is found in Southern Africa, Egypt, 
and parts of Arabia, and gives rise to hematuria. The para- 
site lives in the venous system, particularly in the portal vein, 
and in the veins of the bladder, spleen, and -mesentery. It is 
still unknown how the parasite gains access to the body ; most 
likely, however, from impure drinking-water. 

The most important symptom is a marked hematuria, which 
rapidly produces anemia ; pain usually being present during 
micturition. The urine contains the ova of the bilharzia, 
which is readily recognized under the microscope, being ovoid 
in shape and translucent. The majority of cases recover. 

The important symptoms produced by bronchial flukes are 
hemoptysis and the presence of the parasite in the sputum. 



ROUND-WORMS. 

Ascaris Lumbricoides. — The ascaris lumbricoides is one of 
the most frequent human parasites, occurring particularly in 
children. It is cylindric, pointed at both ends, and has a 
yellowish-brown or reddish color. The male measures 250 
mm. in length, and the female 400 mm. The ova, which com- 
monly occur in the feces of the host, are small and elliptic, with 
a thick covering, measuring 0.075 mm - m length, and 0.058 
mm. in width. They develop outside of the body, but their 
life history is unknown. The parasite infests the upper portion 
of the small intestine ; usually very few are present, but occa- 
sionally enormous numbers may exist. They may pass into the 
stomach, from which they may be vomited. In some rare 
instances the bowel has been perforated and peritonitis has 
occurred. 

Symptoms. — The symptoms are indefinite. The child is 
usually irritable and fretful, picks at the nose, and grinds its 
teeth. There may be twitchings and convulsions. 

Treatment. — Santonin in from three-grain doses in the child 
to proportionately large doses for the adult, followed by calo- 
mel or a saline, is sufficient. 

Oxyuris Vermicularis (Pin-worm, Thread- worm). — This 
common parasite infests the colon and rectum, producing 
great itching and irritation, especially at night. The female 
measures about 10 mm. in length, the male being smaller. 



WORMS. 769 

The parasite is most common in children, but occurs at all 
ages. The worm is easily detected in the feces. 

Treatment. — The treatment consists in the use of santonin 
in small doses, with mild purges. Large injections con- 
taining vinegar, quassia, aloes, turpentine, or carbolic acid 
may be employed. These injections should be continued for 
at least two weeks. 

The ankylostoma duodenale is the only parasite of this 
variety which is injurious to man. It belongs to the same 
variety as the strongylus armata which causes aneurysms in 
the horse. The parasites chiefly inhabit the small intestine. 
The ova measure about 0.05 mm. in their longest diameter. 
The male has a length of from 6 to 10 mm., and the female 
from 10 to 18 mm. The head is somewhat rounded and sup- 
plied with six tooth-like hooklets, by which the parasite fastens 
itself to the mucous membrane of the intestine. It occurs in 
Egypt, in Europe, in India, in Brazil, in Jamaica, and perhaps in 
the Southern United States. 

Symptoms. — The principal symptoms are those of anemia, 
owing to the fact that the parasite withdraws the blood of the 
host. At first there may be only slight gastro-intestinal dis- 
turbance, but when the parasite increases in numbers, anemia 
is characteristic. Egyptian chlorosis is due to this cause. 
The anemia may develop acutely and reach a high grade in a 
short time, with dyspnea and edema. 

Diagnosis. — The diagnosis can be made only from the 
presence of the parasite or of the ova. The larvae develop 
in mud, and easily find their way into drinking-water, in which 
manner infection easily takes place. 

Treatment. — Thymol and male fern destroy the parasite. 
Prophylaxis consists in thoroughly boiling and filtering the 
water used for drinking purposes. 

Trichinae, or trichina spiralis, when they reach their adult 
size, infest the small intestine, trichuriasis being produced 
by the embryos, which, in their passage from the intestines, 
reach the involuntary muscles, where they become encapsu- 
lated, and are then known as muscle trichinae. 

Trichinae occur in two different forms in the human subject — 
in the muscle and in the intestine. The trichina is occasionally 
found in the feces. The male parasite measures 1.5 mm. in 
length, the female being 3 mm. The male has four prominent 
papillae placed between the conical protuberances at the 
extremity. The eggs develop into embryos while still in the 
49 



yjO DISEASES DUE TO ANIMAL PARASITES. 

uterus. The new-born parasite, perforating the gut, becomes 
embedded in the muscles of its host. The worm possesses 
a somewhat pointed head and a rounded tail. 

The young produced by each individual trichina is esti- 
mated at several hundred. When the trichinae reach the 
muscle, they penetrate the muscle-fibers, and here exist 
in their embryonic state. From this process an interstitial 
myositis occurs. The capsule develops about the para- 
site. Several worms may be present in a single capsule. 
This process has been estimated to take about six weeks. 
The parasite does not undergo any further development, 
the capsule becoming thicker and lime-salts infiltrating it. 

In man this process requires from four to six months ; in 
the hog it may take many years. The trichinae may live in 
the muscle for an indefinite period. They have been found 
active after having resided in the muscle of man for from 
twenty to twenty-five years after their entrance into the 
system. Often the worms are completely encapsulated. 

Trichinae occur in hogs, rats, mice, cats, foxes, and other 
animals. Dogs are infected with great difficulty ; cats, more 
readily. An animal in which the living trichinae swarm may 
be well nourished and look perfectly healthy. 

The mode of infection in man is through eating the flesh of 
trichinous hogs. Systematic examination of the meat is ex- 
tremely important. In Germany, where a systematic micro- 
scopic examination is carried on, trichinous hogs are found in 
the proportion of I in 1852. In England and the United 
States systematic inspection is unknown. " Taking all the 
examinations of American pork thus far made, both at home 
and abroad, and we have a total of 298,782, in which trichinae 
were found 6280 times, being 2.1 %, or 1 to 48" (Salmon, 
1884). The disease often appears in epidemics, large num- 
bers of persons being affected from the same source. 

Symptoms. — The disease is not caused when only small 
portions of trichinous meat are partaken of ; few embryos may 
find their way to the muscles, and thus no symptoms are pro- 
duced. In well-marked cases a gastro-intestinal period occurs, 
followed by a period of general infection. After eating infected 
meat, in the course of a few days symptoms of gastro-intestinal 
disturbances develop, such as loss of appetite, nausea, vomiting, 
and occasionally diarrhea. These prodromes are by no means 
constant. In other cases the onset may be acute, with severe 
abdominal symptoms, often resembling an attack of cholera. 



WORMS. 771 

Some weakness and debility, and pains in different parts of the 
body, have been noticed. The symptoms of the constitutional 
disturbance take place in about ten days, sometimes a little 
later. As a rule, there is fever, which is absent only in the 
mildest cases. Chills are rare. The temperature is either 
remittent or intermittent, and may vary between 102 F. and 
104 F. As the parasites attack the muscle-tissue, symptoms 
of myositis develop. There is marked pain upon movement 
and pressure of the affected parts. The muscles are swollen. 
Edema often occurs early and is well marked in the face ; 
later, it appears in the extremities. There is marked sweating 
with urticaria. As a rule, consciousness is not disturbed, ex- 
cept in some cases of extreme gravity, in which the u typhoid 
state " develops. Symptoms of delirium with tremors, dry 
tongue, and tympanitic belly then occur. Often there is dysp- 
nea and some bronchitis. Pneumonia and pleurisy may occur 
as complications. Polyuria has been observed as a symptom in 
some cases. As a rule, albuminuria occurs, and the blood 
shows a marked increase in the eosinophiles. The duration of 
the attack depends upon the severity and the grade of infection. 
The mortality ranges from 2<fc to 30^. 

The prophylaxis depends upon the careful examination of 
the meat, and when pork or sausage is partaken of, it should 
be thoroughly boiled. 

Treatment. — A brisk purge early is advised, and the use of 
glycerin in large doses to destroy the worm has been recom- 
mended by some authorities. Diarrhea early in the course of 
the infection is favorable. When pains become manifest, they 
should be relieved by suitable remedies. The patient's strength 
should be supported. No drug is known that is of value 
in destroying the worm after it has reached the muscle-tissue. 

Filaria. — The female is about 4 cm. in length. The larva, 
as found in the blood of the living subject, is 0.0075 mm - m 
breadth and 0.34 mm. in length. The worm has a long, 
rounded head, with a tongue-like appendage and a short, 
pointed tail. The parasite is found in the blood and lymph- 
channels, and occurs particularly in the tropics ; it has, how- 
ever, been occasionally met with in temperate climates. 

The parasite may be present a long time in the blood 
without giving rise to symptoms. In a number of instances, 
however, it blocks or perforates the capsules or lymphatics, 
leading to chyluria, hematuria, or hemorrhage in different 
organs. 



772 DISEASES DUE TO ANIMAL PARASITES. 

According to some recent investigations, it has been shown 
that the parasite is conveyed by the mosquito. It has been 
found that one variety of the parasite (filaria nocturna) can be 
seen in the peripheral blood only at night ; another variety 
(filaria diurna), during the day; while still another variety 
(filaria perstans) can be found by day as well as by night. 

Some forms of elephantiasis are occasionally due to the 
filaria, and sometimes immense thickening of the tissues of 
the scrotum occurs. In these cases the parasites are not 
always found. 

A variety of filaria known as dracuncidus medinensis (guinea- 
worm disease) occurs in certain parts of Africa and the East 
Indies. It has extremely rarely been met with in this country. 

The worm is usually solitary, is cylindric in form, about 2 
mm. in diameter, and from 50 to 80 mm. in length. Only the 
female is known. The worm gains entrance through the 
stomach and not through the skin. 

Other forms of filaria are known : The filaria loa, which has 
been found in the conjunctiva ; the filaria lentis, occurring in 
cataract ; the filaria labialis ; the filaria hominis oris, occurring 
in the lip and in the mouth ; and the filaria bronchialis, which 
has been found in the trachea and the bronchi. 

Other Nematodes. — The trichocephalus dispar, or whip- 
worm, has been found in the large intestine and cecum, the 
female measuring from 4 to 5 cm., while the male is somewhat 
shorter. As many as a thousand have been counted in one 
case. It rarely causes symptoms. The worm is voided in 
the feces, the eggs being dark brown and lemon-shaped. 

Eustrongylus Gigas. — This measures about 30 cm. in 
length ; the female, about 100 cm. It is rarely met with in 
man. When found in the human subject, it is encountered in 
the renal region and may destroy the kidney. 

Rhabdonema Intestinale. — These are the small worms 
commonly found in the feces, occurring in the endemic diar- 
rhea of tropical climates. They are often found in connec- 
tion with the ankylostoma ; occasionally they are found in 
the biliary and pancreatic ducts. When present in large 
numbers, they give rise to intestinal disturbance with anemia. 



INDEX 



Abdomen, fluid in, 95 

gas in, 95 

inspection of, 93 

palpation of, 94 

percussion of, 95 

regions of, 93 
Abdominal aorta, aneurysm of, 369 

organs, examination of, 92 
Abscess, formation of, in appendicitis, 
492 

of brain, 702 

of liver, 531 

of lung, 405 

of mediastinum, 431 

of pancreas, 549 

perinephritic, 576 

retropharyngeal, 446 

subphrenic, 462 
Absorption of stomach, rate of, 132 
Acetone in urine, 158 
Acetonemia, 150 
Acetonuria, 158 
Acidity, total, of stomach-contents, 

129 
Acme stage of fever, 24 
Acquired atelectasis, 392, 393 

syphilis, 301 
Acromegaly, 645 
Actinomyces, 121 
Actinomycosis, 287 
Acute rheumatic fever, 238 

treatment of, 241 
Addison's anemia, 619 

disease, 630 

treatment of, 633 
Adenie, 625 

Adenitis, tubercular, local, 277 
Adenomata of liver, 534 
Agonal leukocytosis, 147 
Agoraphobia, 733 
Air- hunger in typhoid fever, 182 
Alar chest, 21 
Albumin in urine, 154 
Albuminometer, Esbach's, 155 
Albuminuria, 154* 
Alcoholism, 747 
Alimentary canal, tuberculosis of, 278 



Alkalinity of blood, 136 
Allorrhythmia, 41 
Allorrhythmic pulse, 41 
Ammonia urate in urine, 165 
Ammonia-magnesium phosphate in 

urine, 165 
Amoeba coli, 761 
Amphoric breathing, 72 

voice, 76 
Amyloid disease of arteries, 361 
of heart, 353 
of kidney, 571 
of liver, 520 
Anasarca, 20, 342 
Anemia, 612 

Addison's, 619 

chlorotic, 614 

ganglionic, 620 

of spinal cord, 666 

pernicious, 619 

post-typhoid, 181 

primary, 612 

secondary, 612-617, 619 
pathology of, 614 
symptoms of, 615 
treatment of, 616 

splenic, 629 
Anemic fever, 616, 621 
Aneurysm, cerebral, 701 

cylindric, 366 



dissecting, 
false, 366 



166 



fusiform, 366 

of abdominal aorta, 369 

of arteries, 365 

of heart, 354 

pulsation from, 92 

saccular, 366 

thoracic, physical signs of, 368 

true, 366 
Angina pectoris, 359 

pseudo-, 359 
Angiomata, cavernous, of liver, 534 
Anidrosis, 36 

Animal parasites in sputum, 127 
Ankylostoma duodenale, 769 
Anthracosis, 407 



773 



774 



INDEX. 



Anthrax, 286 

bacillus of, 108 
Antiplague serum, 120 
Antitetanic serum, 115 
Antitoxin, diphtheria, 113 

for tetanus, 115 

injections in diphtheria, 248 

treatment of diphtheria, 247 
Aorta, abdominal, aneurysm of, 369 

pulsating, 94 
Aortic cartilage, 85 

insufficiency, 334 
cor bovinum in, 335 
Corrigan pulse in, 335 
diagnosis of, 336 
Flint murmur in, 336 
physical signs of, 335 
receding pulse in, 335 
water-hammer pulse in, 335 

orifice, stenosis of, 89 

regurgitation, 89 

stenosis, 336 
Apex-beat of heart, 77 
Aphonia in hysteria, 731 
Apnea, 55 
Apoplectic cicatrix, 696 

constitution, 21 

stroke, 696 
Apoplexy, cerebral, 695 

ingravescent, 696 

pulmonary, 396 
Appendicitis, 487 

acute, symptoms of, 491 

causes of, 488 

chronic, 493 

complications and sequels, 493 

fibroid, 490 

formation of abscess in, 492 

gangrenous, 490 

obliterans, 490 

pathology of, 490 

phlegmonous, 490 

physical examination, 492 

relapsing, 493 

ulcerative, 490 
Appendix, 487 
Argyll Robertson pupil in locomotor 

ataxia, 677 
Argyria, 32,758 
Arrhythmic pulse, 41 
Arrhythmia, 356 

Arsenical poisoning, chronic, 757 
Arterial system, examination of, 91 

transmission of murmurs in, 92 
Arteries, amyloid disease of, 361 

aneurysm of, 365 
diagnosis of, 368 
pathology of, 366 
signs of rupture of, 368 



Arteries, aneurysm of, symptoms of, 367 
treatment of, 368 
varieties of, 366 

calcareous infiltration of, 361 

degenerations of, 361 

diseases of, 361-369 

fatty degeneration of, 361 

hyaline degeneration of, 361 

infiltrations of, 361 

inflammation of, 361 

tuberculosis of, 281 
Arteriosclerosis, 362 

diagnosis of, 364 

diffuse, 363 

symptoms of, 364 

treatment of, 365 
Arteritis, 361 

atheromatous, 363 

obliterans, 363 
Arthritic atrophy, 19 
Arthritis deformans, 602 
treatment of, 604 

gonorrheal, 598 
Ascaris lumbricoides, 768 
Ascites, 20, 510 

differential diagnosis of, from ovarian 
cysts, 511 

of abdomen, 95 
Asphyxia, local, 724, 725 
Astasia abasia, 730 
Asthma, bronchial, 386 
treatment of, 388 

rhonchi in, 59 

sputum in, 125 
Atavism, 739 
Atelectasis, acquired, 392, 393 

congenital, 392, 393 

of new-born, 392, 393 

pulmonary, 392, 393 

carnification of lung -tissue in, 

393 
splenization of lung-tissue in, 393 
Atheromatous arteritis, 363 
Atony, 475 
Atrophic rhinitis, 371 
Atrophy, arthritic, 19 
local, 19 
muscular, idiopathic, 738, 741 

facioscapulohumeral form, 740 
juvenile form, 740 
progressive, of Heubner-Strumpell 
variety, 686 
myopathic, 19 
of liver, acute yellow, 529 
progressive, of spinal origin, heredi- 
tary forms of, 685 
infantile forms of, 685 
Auditory nerve, diseases of, 657 
Aurae in epilepsy, 712 



INDEX. 



775 



Auscultation of endocardial murmurs, 
88 
of exocardial murmurs, 90 
of heart, 84 

of pericardial friction sounds, 90 
of respiratory organs, 66, 67 
of valves of heart, anatomic situation 

for, 85 
of voice, 75 

Auscultatory percussion, 64 

Autochthonous pulse, 47 



Babinski's reflex in hysteria, 730 

Baccelli sign, 76 

Bacillus coli communis, no 

differentiation of, from bacillus 
typhosus, in 
colon, no 
comma, 116 
icteroides, 1 20 
mallei, 107 
of anthrax, 108 
of diphtheria, in, 112 

in sputum, 127 
of Friedlander, 104 

in sputum, 127 
of glanders, 107 
of influenza, 118 
in sputum, 127 
of leprosy, 107 
of malignant edema, 1 15 
of Sanarelli, 120 
of tetanus, 1 13, 114 

biologic characteristics of, 1 14 
of tuberculosis, 104 

in sputum, 127 
of yellow fever, 120 
pestis, 119 
plague, 119 
pseudodiphtheria, 113 
pyocyaneus, 102 
tuberculosis, 104 

biologic characteristics of, 106 
in sputum, 105 
typhosus, 108, 109 

differentiation of, from colon bacil- 
lus, in 
"YYidal reaction for detection of, 
109 
"X," 121 
Bacteria found associated with dysen- 
tery, 295 
in feces, 170 
in urine, 163 
peritonitis due to, 505 
Bacteriology, clinical, 100 
Barlow's disease, 635 
Barrel chest, 51 



Basophilic leukocyte, coarsely granular, 

149 
Beef tapeworm, 764 
Bell tympany, 76 
j Bell's palsy, 656 
Benzopurpurin test for free hydrochloric 

acid in stomach-contents, 130 
Beriberi, 653 
Bile acid in urine, tests for, 156 

pigments in urine, tests for, 156 
Bile-stained vomit, 133 
I Bilharzia haematobia, 767 
! Biliary cirrhosis, 525 

passages, diseases of, 538 
Bilious hemorrhagic fever, 203 
Bilirubin crystals in urine, 1 64 
Biology, definition of, 17 
Birth palsy, 7°9 

Black death, 257. See also Plague. 
smallpox, 216 

vomit, 193. See also Yellow Fever. 
Blood, alkalinity of, 136 

animal parasites found in, 150 

coagulability of, 135 

color of, 134 

diseases of, 612 

estimation of hemoglobin in, 136 

examination of, 133 

chemic, 150 
fluidity of, 135 
flukes, 767 

in croupous pneumonia, 234 
in typhoid fever, 181 
in urine, 152 

macroscopic appearance of, 134 
method of procuring, for examina- 
tion, 133 
micro-organisms found in, 150 
nucleated red corpuscles in, 144 
plates, 149 

red corpuscles of, estimation of, 139 
relation between specific gravity and 

hemoglobin of, 135 
sodium chlorid in, 150 
specific gravity of, 135 

method of determining, 135 
staining of, 142, 143 
vomiting of, 133 

white corpuscles of, enumeration of, 
142 
Blood-cells, red, in feces, 170 

in urine, 160 
Blood-corpuscles, red, in sputum, 126 

white, in sputum, 126 
Bloody stools, 169 

Boas' test for free hydrochloric acid in 
stomach-contents, 130 
for lactic acid in stomach-contents, 
30 



776 



INDEX. 



Body, changes in shape of, 19 

changes in size of, 19 

examination of surface of, 19 
Bothriocephalidse, 764 
Bothriocephalus latus, 764 
Bowels, intussusception of, 498 

treatment of, 500 
Brachycardia, 358 
Bradycardia, 41, 358 

in tumor of brain, 707 
Brain, abscess of, 702 

carcinoma of, 705 

cysts of, 705 

diseases of, 692 

glioma of, 705 

inflammation of, 703 

neuroma of, 705 

sarcoma of, 705 

tabes of, 679 

tuberculosis of, 281 

tumors of, 705 
prognosis of, 708 
symptoms of, 706 
treatment of, 708 
Brand's method of treating typhoid 

fever, 185 
Bread-and-butter appearance in acute 

pericarditis, 315 
Breakbone fever, 195 
Breast, chicken-, 53 

pigeon, 53 
Breathing, amphoric, 72 

bronchial, 70, 71 

cavernous, 71 

compensating, 69 

difficult, 56 

laryngeal, 70 

supplementary, 69 

tracheal, 70 

vesicular, 67 

vicarious, 69 
Broadbent's sign, 320 
Bronchi, diseases of, 376 

inflammation of, 376. See also ./?;-<?//- 
chitis. 
Bronchial asthma, 386 

breathing, 70, 71 

cast, fibrinous, 125 

flukes, 767 
Bronchiectasis, 383 

diagnosis of, 38 \ 

physical signs of, 384 

sputum in, 384 

symptoms of, 384 

treatment of, 385 
Bronchitis, 376 

acute, simple, 376 

treatment of, 378 

chronic, 381 



Bronchitis, chronic, treatment of, 383 

dry, 382 

fetid, 582 

fibrinous, 379 

symptoms of acute form of, 379 

of chronic forms of, 379 
treatment of. 380 

rhonchi in, 59, 60 
Bronchocavernous respiration, 72 
Bronchophony, 76 
Bronchopneumonia, 397 

complications of, 399 

diagnosis of, 399 

differential, from croupous pneu- 
monia, 400 

pathology of, 398 

physical signs of, 399 

symptoms of, 398 

treatment of, 400 
Bronchopulmonary hemorrhage, 394. 

See also Hemoptysis. 
Bronchorrhea, 382 
Bronchovesicular respiration, 72 
Bruit de diable, 48 
Bubo, parotid, 441 
Bubonic plague, 257 
Bulbar paralysis, progressive, 690 
Bulimia, 474 

Buttonhole mitral valve, 333 
Butyric acid, tests for, in stomach-con- 
tents, 131 



Cachexia, 20 

malarial, 203, 204 

malignant, 21 

phthisical, 20 

expiratory form of chest in, 2 1 

scrofulous, 20 

splenic, 629 
Cadaverin, 742 
Calcium phosphate in urine, 165 

sulphate in urine, 165 
Calculi, pancreatic, 553 

renal, 583 
Cancer of stomach, 465 
Capillary pulse, 91 
Caput medusae, 47, 523 
Carcinoma of brain, 705 

of intestines, 502 

of kidney, 580 

of liver, 535 

of pancreas, 552 

of peritoneum, 513 

of stomach, 465 
Carnification of lung-tissue in atelecta- 



sis, 393 
Cartilage, aortic, 85 
Casts, 161. Plate II. 



INDEX. 



777 



Casts, cylindroid, 162 
due to coalescence, 161 
due to degeneration of cells, 161 
due to infiltration, 162 
fibrinous bronchial, 125 
in feces, 169 
in sputum, 125 
hyaline, 162 
in urine, 161 

method of examination, 163 
unorganized, 162 
Cat tongue in scarlet fever, 205 
Catarrh, chronic, simple, 371 
intestinal, 475 
nasal, acute, 370 
chronic, 371 
Cavernous breathing, 71 
Cells, blood-, red, in feces, 170 
casts due to degeneration of, 161 
epithelioid, 264 
in feces, 170 
in sputum, 1 27 
giant, 264 
lymphoid, 264 
Cercomonas intestinalis, 762 
Cerebellum, hemorrhage into, 698 
Cerebral aneurysms, 701 
apoplexy, 695 
hemorrhage, 695 
palsies of children, 709 
rheumatism, 240 
Cerebrospinal fever, 248 
diagnosis of, 251 
etiology of, 249 
Kernig's sign in, 251 
symptoms of, 249, 250 
treatment of, 252 
varieties of, 250 
meningitis, 248 
Cestodes, 763. See also Tapeworms. 
Chalicosis, 407 
Chancre, 300 

Hunterian, 301 
Charcot-Leyden crystals in sputum, 126 
Charcot's fever, 540 

joints, 679 
Chart, fever, 262 
Chauveau's fluid vein theory, 89 
Chemic examination of stomach-con- 
tents, 129 
of urine, 154 
Chest, alar, 21, 52 
barrel, 51 
chicken-breast, 53 
diaphragm phenomenon of, 54 
emphysematous, 51 
expiratory form of, 21, 52 
funnel-shaped, 53 
Harrison's grooves in, 53 



Chest in rachitis, 53 

inspiratory form of, 51 

retraction of intercostal spaces, 54 

irregular forms of, 53 

paralytic, 52 

pathologic forms of, 51 

phthisical, 52 

phthisoid, 21 

pigeon-breast, 53 

pterygoid, 21, 52 

respiratory type of, 53 

Schusterbrust, 53 

trichterbrust, 53 

unilateral expansion of, 52 
Cheyne- Stokes respiration, 55 
Chicken-breast, 53 
Chickenpox, 223 
Children, enteritis of, 480 
Chills and fever, 196. See also Ma- 
laria. 
Chlorid of sodium in blood, 150 

in urine, 166 
Chlorosis, 617 

fiorida, 618 

tarda, 617 

treatment of, 619 
Cholangitis, suppurative, 540 
Cholelithiasis, 541 

treatment of, 545 
Cholemia, 31 
Cholera, 252 

diagnosis of, 256 

fulminosa, 256 

infantum, 480, 48 1 

morbus, 484 

prognosis of, 256 

red reaction, 1 17 

rice-water stools in, 254 

sicca, 256 

spirillum of, 1 16 

stages of, 254 

symptoms of, 254 

toxica, 256 

treatment of, 256, 257 

typhoid, 255 
Cholerine, 254, 256 
Cholesterin crystals in sputum, 126 

in urine, 166 
Cholin, 742 
Chorea, 716 

habit-, 718 

hereditary, 719 

Huntingdon's, 719 

insaniens, 718 

maniacal, 718 

of larynx, 719 

paralytic, 718 

spastica in infantile hemiplegia, 710 
Choreiform affections, 718 



77* 



INDEX. 



Chylous pleurisy, 420 
Chyluria, color of urine in, 153 
Cicatrices, 34 
Circulation, collateral, 513 

diseases of, 313-369 
Circulatory apparatus, diseases of, as 
cause of cyanosis, 30 

system in typhoid fever, 1 80 
Circumscribed edema, acute, 723 
Cirrhosis, biliary, 525 

congestion, 525 

due to malaria, 526 

hypertrophic, 527 
treatment of, 529 

of liver, atrophic, 521 

of lung, 401 

syphilitic, 526 
Claustrophobia, 734 
Clinical bacteriology, 100 
Cloudy swelling, 559 
Coagulability of blood, 135 
Coal-gas poisoning, 752 
Cobra-bite, 746 
Coccidia, 761 
Coccidium oviforme, 761 
Cog-wheel respiration, 70 
Colic, hepatic, 543 

lead, 754 
Colitis, 477 
Collapse, 26 
Collar of brawn, 208 
Collateral circulation, 5 13 
Colles' law, 300 
Colon bacillus, no 
Color index in hemoglobin, 146 

of blood, 134 

of feces, 168 

of skin in disease, 27 

of sputum, 124 

of urine, 151, 152 
Coma, 22, 23 

diabetic, 594 
Comma bacillus, 116 
Compensatory breathing, 69 
Concealed hemorrhage in typhoid fever, 

182 
Congestion, active, of liver, 515 

cirrhosis, 525 

of kidneys, 556 

of lungs, 403 

passive, of liver, 517 
Consciousness, 22 
Constipation, 167 
Constitutional diseases, 590 
Consumption, 268 

galloping, 269 
Continued fever, 23,- 171 

simple, 171 
Convulsions, infantile, 715 



Cor bovinum in aortic insufficiency, 

335 
Cord, tuberculosis of, 281 
Corpulency, 609 
Corpuscles, phantom, 127, 146 
in urine, 160 
shadow, 127, 146 
in urine, 160 
Corrigan pulse, 42, 335 
Coryza fcetida, 371 
Cough, hysteric, 731 
Cowpox, 219. See also Vaccinia. 
Cracked-pot sound, 65 
Crackling rale, 74 
Cranial nerves, diseases of, 654 
Craniotabes, 601 
Crepitant rales, 73, 74 
Crepitation, 73, 74 
Cretinism, sporadic, 642 
Crisis, false, in fever, 25 
of fever, 24 
pseudo-, in fever, 25 
Critical discharges in fever, 25 
Crossed hemiplegia in apoplexy, 697 
Croup, 375 

membranous, 242. See also Diph- 
theria. 
Croupous enteritis, 479 
pneumonia, 228 

complications of, 236 
diagnosis of, 236 
pathology of, 229 
physical examination in, 234 
prognosis of, 237 
prune-juice sputum in, 233 
rusty sputum in, 233 
stages of, 229 
symptoms of, 230 
blood, 234 
dige'stive system, 233 
nervous, 233 
pulse, 233 
respiration, 232 
special, 232 
sputum, 233 
temperature, 232 
urine, 233 
temperature-curve of, 231 
treatment of, 237 
varieties of, 235 
Crus. hemorrhage into, 697 
Crystals, Plate III 

Charcot-Leyden, in sputum, 126 
cholesterin, in sputum, 126. 
hematoidin, in sputum, 126 
in feces, 170 
in sputum, 126 

triple phosphate, in sputum, 126 
Cyanosis, 27, 29 



INDEX. 



779 



Cyanosis caused by diseases of circula- 
tory apparatus, 30 
caused by diseases of respiratory 
organs, 29 
Cylindric aneurysm, 366 
Cylindroid casts, 162 
Cystin in urine, 165 
Cysts of brain, 705 
of kidney, 582 
of pancreas, 552 
of peritoneum, 514 
ovarian, diagnosis, differential, 'from 
ascites, 511 



Dalrymple's sign, 644 
Dana and Putnam's combined sclerosis 
of lateral and posterior columns, 682 
Dare's hemoglobinometer, 138 
Death-rattle in pulmonary edema, 405 
Declining stage of fever, 24 
Decubitus, the, 21 
Defervescent stage of fever, 24 
Degeneration, fatty, of arteries, 361 
of heart, 351 
of kidney, 576 
hyaline, of arteries, 361 
of arteries, 361 
parenchymatous, 351 
Deitl's crises, 583 
Delirium, 22 

tremens, 749 
Dengue, 195 

treatment of, 196 
Diabetes insipidus, 595 
mellitus, 590 
acute, 591 
chronic, 592 
diagnosis of, 594 
treatment of, 595 
urine in, 593 
Diabetic coma, 594 
Diacetic acid in urine, 158 

test for, 159 
Diagnosis, physical, 49 
definition of, 18 
of heart, 77 
Diaphragm phenomenon, 54 
Diaphragmatic pleurisy, 419 
Diarrhea, 167 

dyspeptic, acute, 480 
lienteric, 477 
Diastolic collapse of veins, 48 
Diazo reaction, Ehrlich's, 159 
Dicrotism, 41 

Diffused impulse of heart, 81 
Diffusibility of apex-beat of heart, 77 
Digestive system in croupous pneu- 
monia, 233 



Digestive system in typhoid fever, 1 81 

tract, diseases of, 434 
Dilatation of esophagus, 45 1 

of heart, 347 

of stomach, 471 
Dimpling, systolic, 80 
Diphtheria, 242 

antitoxin for, 113 

bacillus of, 11 1, 112 
in sputum, 127 

complicating scarlet fever, 207 

diagnosis of, 246 

differential, from acute follicular 
tonsillitis, 443 

laryngeal, 245 

pathology of, 243 

prognosis of, 246 

symptoms of, 244 

treatment of, 246 
antitoxin, 247 
prophylaxis, 246 
Diphtheric dysentery, 296 

paralysis, 246 
Diplococcus intracellularis meningitidis, 
102 

lanceolatus, 103 

of pneumonia, 104 
in sputum, 127 
Disease (diseases), 17 

constitutional, 590 

divisions of, 18 

due to animal parasites, 761 

endemic, 18 

epidemic, 18 

infectious, 171 

of arteries, 361 

of biliary passages, 538 

of blood, 612 

of brain, 692 

of bronchi, 376 

of circulation, 313 

of digestive tract, 434 

of ductless glands, 612 

of esophagus, 447 

of hepatic artery, 548 
veins, 548 
vessels, 546 

of intestines, 475 

of kidneys, 556 

of larynx, 372 

of liver, 515 

of mediastinum, 430 

of medulla and pons, 690 

of mouth, 434 

of muscles, 736 

of myocardium, 350 

of nerves, 647 
cranial, 654 

of nervous system, 647 



;8o 



INDEX. 



Disease (diseases) of nervous system, 
general and functional, 711 

of nose, 370 

of pancreas, 549 

of pericardium, 314 

of peritoneum, 504 

of pharynx, 445 

of pleura, 410 

of portal vein, 546 

of pulmonary structure, 390 

of respiratory system, 370 

of salivary glands, 440 

of spinal cord, 660 

of stomach, 452 

of tongue, 439 

of tonsils, 441 

pandemic, 18 

sporadic, 18 
Displacements of liver, 515 
Dissecting aneurysm, 366 
Distomidae, 767 
Dittrich's plug, 125 
Divers' paralysis, 666 
Dorsal position in bed, passive, 21 
Dracunculus medinensis, 772 
Dropsy, 19 

in acute diffuse nephritis, 561 

of peritoneal cavity, 20 
Drugs, influence of, on color of urine, 

153 
Dry bronchitis, 382 

pleurisy, 410 

rales, 73 
Duchenne's disease, 690 
Ductless glands, diseases of, 612 
Duodenitis, 477 
Dura mater, hematoma of, 692 
Dysentery, 295 

acute catarrhal, 296 

amebic, 298 

bacteriology of, 295 

diphtheric, 296 

secondary, 299 

tropic, 298 
Dyspepsia, 458 

chronic, 456 

nervous, 450, 474 
Dyspnea, 56 



Eccentric hypertrophy of heart, 344 
Ecchymosis, 34 
Echinococcus of pleura, 430 
Eclampsia, 715 
Edema, 20, 34 

acute circumscribed, 7 2 3 

malignant, bacillus of, 115 

of larynx, 373 

pretibial, 561 



Edema, pulmonary, 404 
Effusions, encapsulated, of pleura, 416 
pleurisy with, 424 

treatment of, at extremes of age, 423 
Egophony, 76 
Egyptian chlorosis, 614 
Ehrlich's diazo reaction, 159 

method for blood-staining, 143 
Elephantiasis due to filaria, 772 
Emaciation, 19 
Embolism, 700 
Emphysema of skin, 35 
spontaneous, 35 
pseudohypertrophic, 390 
vesicular, 390 

treatment of, 392 
Emprosthotonos, 22 
Empyema, 416 

necessitatis, 58, 418, 421 
pulsating, 60 
Encapsulated effusions of pleura, 416 

pleurisy, 421 
Encephalitis, 703 
Encephalopathy, lead, 755 
Encysted pleurisy, 421 
Endemic disease, 18 
Endocardial murmurs, auscultation of, 
88 
functional, 89 
hemic, 89 
inorganic, 89 
musical, 88 
organic, 89 
sounds, 82, 83 

differential diagnosis of, from exo- 
cardial sounds, 90 
Endocarditis, acute, 323 
simple, 324 

treatment of, 327 
chronic, 330 

diagnosis of, 332 
infective, 327 

treatment of, 330 
types of, 328 
cardiac, 329 
cerebral, 329 
malarial, 329 
pyemic, 328 
septic, 328 
typhoid, 329 
mural, 323 
sclerotic, 330 
Endocardium, inflammation of, 323 
Enteric fever, 175. See also Typhoid 
fever. 
characteristic eruption of, 34 
Widal reaction in, 109 
Enteritis, catarrhal, acute, 475 
treatment of, 478 



INDEX. 



781 



Enteritis, catarrhal, chronic, 475 
treatment of, 478 

croupous, 479 

mucous, 482 

of children, 480 
treatment of, 482 

phlegmonous, 479 
Enterocolitis, acute, 480, 481 
Enteroliths, 169 
Enteroptosis, 473, 486 
Enterorrhagia, 485 
Eosinophils, 148 

polynuclear, 148 
Epidemic disease, 18 
Epigastric pulsation, 92 
Epilepsy, 711 

Jacksonian, 715 

major, 712 

minor, 713 

nocturnal, 713 

psychic, 713 

symptoms of, 711 
postepileptic, 713 

treatment of, 714 
Epileptic cry, 712 
Epithelial cells in sputum, 127 
Epithelioid cells, 264 
Epithelium in feces, 170 

in urine, 159 
Erb's palsy, 680 
Eruptions, 2>?> 

in typhus fever, 188 

roseolar, ^ 
Eruptive fevers, 204 
Erysipelas, 224 

ambulans, 226 

surgical, 227 

treatment of, 227 

wandering, 226 
Erythrocytes, description of, 1 43 
Erythromelalgia, 725 
Esbach's albuminometer, 155 
Esophagismus, 448 
Esophagitis, acute, 447 

chronic, 448 
Esophagus, dilatation of, 45 1 

diseases of, 447 

rupture of, 451 

spasm of, 448 

stricture of, 449 

tumors of, 450 
Estivo-autumnal fever, 197, 202 
forms of, 200 
temperature-curve in, 200 
varieties of, 200 
Etiology, definition of, 17 
Eustrongylus gigas, 772 
Evacuation of stomach, method for, 

128 



i Evacuation of stomach, introduction of 

tube for, 128 
Ewald's test-meal, 128 
Exacerbation in temperature, 23 
Examination of abdominal organs, 92 

of arterial system, 91 

of blood, 133 

of casts, 163 

of feces, 166 

of liver, 97 

of respiratory organs, 49 

of skin, 26 

of spleen, 98 
• of sputum, 122 

of stomach-contents, 128 

of surface of body, 19 

of urine, 151 

physical, in croupous pneumonia, 

234 
of stomach, 96 
Exanthemata, ^t„ 204 
Exhaustion, heat- ,759 
Exocardial murmurs, auscultation of, 90 
sounds, differential diagnosis of, from 
endocardial sounds, 90 
Exophthalmic goiter, 643 
treatment of, 645 . 
Expansile pulsation, 92 
Expiration, prolonged, vesicular breath- 
ing with, 70 
Expiratory form of chest, 21 



Facial hemiatrophy, 722 

paralysis, 656 

tic, 719 
Facies, 22 

hippocratica, 22 
Facioscapulohumeral form of progres- 
sive muscular atrophy, 740 
False aneurysm, 366 
• crisis in fever, 25 
Farcy buds, 304 
Fastigium stage of fever, 24 
Fat necrosis of pancreas, 554 
Fatty degeneration of arteries, 361 
of heart, 351 
of kidney, 576 

infiltration of heart, 350 
of kidney, 576 

liver, 518 

stools, 168 
Fecal vomiting, 133 
Feces, amount of, 167 

bacteria in, 170 

character of, 168 

color of, 168 

consistence of, 168 

crystals in, 170 



782 



INDEX. 



Feces, enteroliths in, 169 

epithelium in, 170 

examination of, 166 
macroscopic, 1 67 
microscopic, 169 

fibrinous casts in, 169 

gall-stones in, 169 

leukocytes in, 170 

odor of, 168 

reaction of, 168 

red blood-cells in, 170 

rice-water, 168 

shreds of tissue in, 169 
Fehling's solution, 157 

test for grape-sugar in urine, 157 
Fermentation test for grape-sugar in 

urine, 157 
Fetid bronchitis, 382 
Fever (fevers), acute rheumatic, 238 

anemic, 616, 621 

bilious hemorrhagic, 203 

breakbone, 195 

cerebrospinal, 248 

Charcot's, 540 

chart, 262 

chills and, 196. See also Malaria. 

continued, 171 

crisis of, 24 

critical discharges in, 25 

enteric, 175. See also Typhoid fever. 
characteristic eruption of, 34 
Widal reaction in, 109 

eruptive, 204 

estivo-autumnal, 197, 202 

false crisis in, 25 

hay-, 388 

hepatic, 540 

hysteric, 732 

infantile remittent, 180, 184 

lysis of, 24 

malarial, 196 

Malta, 311 

miliary, 288 

mountain, 290 

periodic, 196 

preagonistic rise in, 25 

precritical rise in, 25 

prodromes in, 24 

pseudocrisis in, 25 

quartan, 197, 201 

relapsing, 190 
spirillum of, 1 17 

rose, 388 

scarlet, 204 

simple continued, 17 1 
splenic, 286 

spotted, 248. See also Cerebrospinal 

fever. 
stages of, 24 



Fever (fevers), tertian, 197, 200 
three-day, 195 
types of, continued, 23 
intermittent, 23, 24 
inverse, 23 
remittent, 23, 24 
subcontinued, 24 
typhoid, 175. See also Typhoid 
fever. 
Widal reaction in, 109 
typhus, 186. See also Typhus fever. 
with marked local manifestations, 228 
yellow, 193 

bacillus of, 120 
Fibrinous casts in feces, 169 
in sputum, 125 
pleurisy, 410. See also Pleurisy, 
dry. 
Fibroid phthisis, 275 

pneumonia, chronic, 401 
thickening of pleura, 416 
Fibromata of liver, 534 
Fifth nerve, diseases of, 655 
Filaria, 771 

as cause of elephantiasis, 772 
bronchialis, 772 
diurna, 772 
hominis oris, 772 
labialis, 772 
lentis, 772 
loa, 772 
nocturna, 772 
perstans, 772 
Finkler and Prior, spirillum of, 118 
Flat- worms, 763 
Flint murmur in aortic insufficiency, 

336 
Floating kidney, 583 
Fluctuation, presence of, in abdominal 
palpation, 95 

upon palpation in region of thorax, 

Fluid in abdomen, 95 
Fluidity of blood, 135 
Flukes, blood, 767 

bronchial, 767 

liver, 767 
Food, poisoning by, 742 
Foot-and-mouth disease, 306 
Force in vesicular breathing, 68 
Foreign bodies in stomach, 470 
Fowler's test for urea in urine, 166 
Frankel's pneumococcus, 103 
Fremitus, pectoral, 58 

tactile, 58 

vocal, 58 
Frequency of pulse, 37 
Friction, pleuropericardial, 75, 91 

sounds, 73 



INDEX. 



83 



Friction sounds of heart, 82 
pericardial, 90 
pleuritic, 75 
Friedlander's bacillus in sputum, 127 

pneumonia bacillus, 104 
Friedreich's ataxia, 683 

sign, 4 8 > 3 21 
Functional and organic murmurs, differ- 
ential diagnosis of, 90 
endocardial murmurs, 89 
Funnel-breast in tuberculosis, 273 
Fusiform aneurysm, 366 - 



Galacturia, color of urine in, 153 
Gallop rhythm, 87 
Galloping consumption, 269 
Gall-stones, 541 

in stools, 169 
Gangrene, local, 724, 725 

of lung, 405 

symmetric, 724, 725 
Gas in abdomen, 95 
Gastralgia, 474 
Gastrectasis, 96, 471 

treatment of, 473 
Gastritis, 452 

acute, severe, 453 

treatment of, 455 
simple, 452 

chronic, 456 

gastric contents in, 457 

mycotic, 452 

phlegmonous, 455 

toxic, 453 
Gastroptosis, 471, 473 
Genito-urinary system, tuberculosis of, 

280 
Gerlach's valve, 488 
Giant cells, 264 

Gilles de la Tourette's disease, 719 
Girdle pain in locomotor ataxia, 678 
Glanders, 304 

bacillus of, 107 

farcy buds in, 305 

treatment of, 306 
Glenard's disease, 473, 486 
Glioma of brain, 705 
Globus hystericus, 729 
Glomerulonephritis. 559 
Glossitis, acute, 439 

chronic, 439 
Glossopharvngeal nerve, diseases of, 

657 
Glycosuria, 156, 590 
pathologic, 157 
persistent, 157 
physiologic, 157 
temporary, 593 



Gmelin's test for bile pigments and 
bile acids in urine, Rosenbach's mod- 
ification of, 156 

Goiter, exophthalmic, 643 

Gonococcus, 102 

Gonorrheal arthritis, 598 

Gout, 604 
acute, 605 
chronic, 606 
irregular, 606 
poor man' s, 604 
retrocedent, 606 
symptoms referable to eye, 606 

to skin, 606 
treatment of, 606, 607 

Gowers' hemoglobinometer, 138 

Grain-poisoning, 743 

Grand mal, 712 

Grape-sugar in urine, 156 

Growths, new, and parasites of heart, 

355 
of pericardium, 323 
of lung, 409 
Guinea- worm disease, 772 
Gull and Sutton's disease, 362 
Giinzburg's test for free hydrochloric 

acid in ston 
Gurgling rales, 74 
Gutta cadeus, 74 



Habit-chorea, 718 
Habit-spasm, 718 
Hallucinations, 22 

Hammerschlag' s modification of Roy' s 
method for determination of specific 
gravity of blood, 135 
Harrison's grooves in chest, 53 
Harsh respiration, 72 
Hay-fever, 388 
Health, definition of, 17 
Heart, amyloid disease of, 353 
aneurysm of, 354 
apex-beat of, 77 
auscultation of, 84 
congenital malformation of, 313 
diffused impulse of, 81 
dilatation of, acute, 347 
chronic, 348 

treatment of, 350 
simple, 347 
fatty degeneration of, 351 

infiltration of, 350 
friction sounds of, 82 
hypertrophy of, 344 
eccentric, 344 
treatment of, 347 
inspection of, 77 
irritable, 357 



;8 4 



INDEX. 



Heart, neuroses of, 356-360 
angina pectoris, 359 
arrhythmia, 356 
brachycardia, 358 
bradycardia, 358 
irritable heart, 357 
palpitation, 356 
pseudo-angina pectoris, 359 
tachycardia, 358 
new growths and parasites of, 355 
ox, in aortic insufficiency, 335 
in chronic pericarditis, 319 
palpation of, -82 

parenchymatous degeneration of, 35 1 
percussion of, 84 
physical diagnosis of, 77 
right, diseases of, 90 
rupture of, 355 
tuberculosis of, 281 
Heart-sounds, auscultation of, 85 
reduplication of, 87* 
rhythm of, 86 
Heat exhaustion, 759 
Heat-and-acid test for albumin in 

urine, 154 
Hedge-hog crystals in urine, 165 
Heller's test for albumin in urine, 155 
Hematemesis, 133, 470 
Hematoidin crystals in sputum, 126 

in urine, 164 
Hematoma of dura mater, 692 
Hematuria, color of urine in, 152 
Hemiatrophy, facial, 722 
Hemic murmur, 89 
Hemichorea, 718 
Hemidrosis, 36 
Hemiglossitis, 439 
Hemiplegia, crossed, in apoplexy, 697 

infantile, 710 
Hemoglobin, 146 
estimation of, 136 
relation of, to specific gravity of blood, 

135 
Hemoglobinometer, Dare's, 138 

Gowers', 138 

Oliver's, 137 

von Fleischl's, 136 
Hemohepatogenous jaundice, 31 
Hemokonien, 150 
Hemopericardium, 322 
Hemophilia, 638 
Hemoptysis, 394 

differential diagnosis of, 396 
Hemorrhage, bronchopulmonary, 394 

cerebral, 695 

secondary phenomena of, 698 
treatment of, 699 

concealed, in typhoid fever, 182 

from stomach, 470 



Hemorrhage in typhoid fever, 18 1 

into cerebellum, symptoms of, 698 

into crus, symptoms of, 697 

into medulla, 698 

into medulla and pons, 691 

into pancreas, 553 

into pons varolii, 697 

into spinal cord, 667 
membranes, 664 

meningeal, symptoms of, 698 

pulmonary, 394 
treatment of, 397 

under skin, 34 

ventricular, 698 
Hemorrhagic fever, bilious, 203 

infarct, 396 

pleurisy, 420 
Hemorrhoids, 500 
Hemothorax, 428 
Henoch's purpura, 637 
Hepatic artery, disease of, 548 

colic, 543 

fever, 540 

veins, disease of, 548 
inflammation of, 548 

vessels, diseases of, 546 
Hepatogenous jaundice, 31 
Hereditary chorea, 719 

forms of progressive atrophy of spinal 
origin, 685 
Herpes, 33 

Heubner-Strvimpell variety of progres- 
sive muscular atrophy, 686 
Hippocratic succussion, 76 
Hobnail liver, 521 
Hodgkin's disease, 625 

treatment of, 628 
Horrors, 749 
Hour-glass contraction, 474 

stomach, 460 
Humanized virus, 222 
Hunterian chancre, 301 
Huntingdon's chorea, 719 
Hyaline casts, 162 

cells, 148 

degeneration of arteries, 361 
Hydatid fremitus, 767 

thrill, 98, 767 

worms, 764-767 
Hydrocephalic cry, 267 
Hydrocephalus, 704 
Hydrochloric acid, free, tests for, in 

stomach-contents, 130 
Hydronephrosis, 578, 579 
Hydropericardium, 321 
Hydrophobia, 307 
Hydrothorax, 65, 427 
Hygiene, definition of, 17 
Hyperacidity, 474 



INDEX. 



785 



Hyperchlorhydria, 474 
Hyperdicrotic pulse, 41 
Hyperemia, 403, 515 

active, 556 

compensatory, 556 

of spinal cord, 666 

passive, 517, 556 
Hyperhidrosis, 36 
Hyperpyrexia, 25 
Hyperresonance, 63 
Hypersecretion, 440 
Hypertrophic cirrhosis, 527 

rhinitis, 371 
Hypertrophy, muscular, idiopathic, 738 

of heart, 344 
Hyphidrosis, 36 

Hypoglossal nerve, diseases of, 658 
Hypoleukocytosis, 147 
Hypostatic pneumonia, 404 
Hysteria, 728 

treatment of, 732 
Hysteric clavus, 730 

cough, 731 

fever, 732 

paroxysm, 729 



Icterus, 30. See also Jaundice. 

neonatorum, 32, 539 
Idiopathic muscular atrophy, 738-741 
hypertrophy, 738 
tetanus, 115 
Ileitis, 477 
Illusions, 22 

Immediate auscultation of respiratory 
organs, 66 
of voice, 75 
percussion, 61 
Impulse, diffused, of heart, 81 
Indicanuria, color of urine in, 153 
Infantile convulsions, 715 

forms of progressive atrophy of spinal 

origin, 685 
hemiplegia, 710 
remittent fever, 180, 184 
Infarct, hemorrhagic, 396 
Infections without special classification, 

262 
Infectious diseases, 171 

theory of causation of acute rheu- 
matic fever, 239 
Infiltration, calcareous, of arteries, 361 
casts due to, 162 
fatty, of heart, 350 

of kidney, 576 
of arteries, 361 
Inflammation of brain, 203 
of hepatic veins, 548 
of mediastinum, 430 
50 



Inflammation of pancreas, 549 

of pia arachnoid, 693 

of portal vein, 547 

of salivary glands, 440 
! Inflammatory leukocytosis, 147 
Influenza, 172 

bacillus of, in sputum, 127 

complications of, 174 

sequels of, 174 

spirillum of, 118 

treatment of, 1 74 

varieties of, 172 
Ingravescent apoplexy, 696 
Inorganic endocardial murmur, 89 
Insanity, preepileptic, 712 
Inspection of abdomen, 93 

of heart, 77 

of liver, 97 

of respiratory organs, 50 
Inspiration, jerking, 70 
Intercostal spaces, inspiratory retrac- 
tion of, 54 
Intercurrent diseases of typhoid fever, 

184 
Interlobular pleurisy, 421 
Intermittent type of fever, 23, 24 
Interrupted vesicular breathing, 68 
Intestines, carcinoma of, 502 
treatment of, 504 

catarrh of, 475 

diseases of, 475 

obstruction of, 495 
treatment of. 497 

sarcoma of, 504 

tuberculosis of, 279 

tumors of, 501, 502 

ulceration of, 483 
Intoxications, 742 
Intussusception of bowels, 498 
Invasion period of fever, 24 
Inverse fever type of temperature, 23 
Irritable heart, 357 



JACKSONIAN epilepsy, 715 
Jaundice, "catarrhal, 538 

detection of, 30 

hemohepatogenous, 31 

hepatogenous, 31 

obstructive, 538 

of new-born, 32, 539 

skin in, 30 

toxemic, 538 
Jejunitis, 477 
Jerking inspiration, 70 

respiration, 70 
Joffroy's sign, 618 
Jumpers, 719 
Jumping disease, 719 



yS6 



INDEX. 



Kernig's sign, 251 

Kidney, amyloid disease of, 571 

carcinoma of, 580 

chronic hemorrhagic, 562 

cirrhotic, 562 

congestion of, 556 

cysts of, 582 

disease of, 556 

fatty degeneration of, 576 
infiltration of, 576 

floating, 583 

large white, 562 

malformation of, 582 

malposition of, 583 

mottled, 562 

movable, 583 

palpable, 583 

sarcoma of, 581 

tuberculosis of, 280 

tumors' of, 580 
Knife-grinders 1 phthisis, 407 
Koch's tuberculin, 106 
Koplik's sign in measles, 21 1 



Laboratory methods, 122 
Lactic acid, tests for, in stomach-con- 
tents, 130 
Boas', 130 
quantitative, 131 
Uffelmann's, 130 
Laennec, perles of, 126 
La grippe, 172. See also Influenza. 
Landry' s paralysis, 675 
Laryngeal breathing, 70 

diphtheria, 245 

tic, 719 
Laryngismus stridulus, 374 
Laryngitis, 372 
Larynx, chorea of, 719 

diseases of, 372 

edema of, 373 

inflammation of, 372 

spasm of, 374 
Lead colic, 754 

encephalopathy, 755 
Lead-poisoning, chronic, 753 
Legal' s test for acetone in urine, 158 
Leprosy, 291 

bacillus of, 107 

treatment of, 294 
Leptomeningitis, acute, 693 

chronic, 694 
Lesions, valvular, 342 
Leucin in urine, 165 
Leukemia, 621 

plethora in, 624 

splenomedullary, 624 

treatment of, 625 



Leukocytes, 146 
in feces, 170 
in urine, 160 
varieties of, 147 
Leukocytosis, 146 
agonal, 147 
inflammatory, 147 
pathologic, 146, 147 
physiologic, 146 
posthemorrhagic, 147 
terminal, 147 
Leukopenia, 147 
L'homme a petitis papiers, 734 
Lieben's test for acetone in urine, 158 
Lienteric diarrhea, 477 
Lightning pains in locomotor ataxia, 

676 
Lime, oxalate of, in urine, 164 

"urate of, in urine, 164 
Lipemia, 150 
Lithemia, 607 
Liver, abscess of, 531 
embolic, 532 
large .solitary. 532 
multiple, 532 
primary, 531 
pyemic, 532 
secondary, 531 
treatment of, 534 
tropical, 532 
adenomata of, 534 
amyloid disease of, 520 
atrophy of, acute yellow, 529 

treatment of, 531 
carcinoma of, 535 
cavernous angiomata of, 534 
cirrhosis of, atrophic, 521 

treatment of, 524 
congestion of, active, 515 

passive, 517 
diseases of, 515 
displacements of, 515 
examination of, 97 
fatty, 518 

treatment of, 520 
fibromata of, 534 
flukes, 767 
hobnail, 521 
in typhoid fever, 182 
inspection of, 97 
lymphangiomata of, 534 
nutmeg, 516, 517 

appearance of, 343 
palpation of, 97 
percussion of, 98 
pulsation of, 97 
sarcoma of, 536 
tuberculosis of, 280 
tumors of, 534~537 



INDEX. 



87 



Liver, tumors of, benign, 534 
malignant, 535 
prognosis of, 537 
symptoms of, 536 
treatment of, 537 
wandering, 97 
Livid skin, 29 

Lockjaw, 309. See also Tetamis. 
Locomotor ataxia, 676 
course of, 679 
diagnosis of, 679 
prognosis of, 679 
stages of, 676 
symptoms of, 676 

special description of, 678 
treatment of, 680 
Loffler's toluol solution, 247 
Lumbago, 600 
Lung, abscess of, 405 

cirrhosis of, 401. See also Pneu- 
monia, chro7iic fibi'oid. 
congestion of, 403 
gangrene of, 405 
new growths of, 409 
parasites of, 410 
primary tumors of, 409 
secondary tumors of, 409 
syphilis of, 407, 408 
tissue, carnification of, in atelectasis, 

393 
splenization of, in atelectasis, 393 
tuberculosis of, 268 
Lymph, vaccine, 219 
Lymphadenitis, tubercular, generalized, 

'277 
Lymphangiomata of liver, 534 
Lymph-glands, tuberculosis of, 276 
Lymphocytes, 148 
Lymphoid cells, 264 
Lysis of fever, 24 



Macrocyte, 144 
Macrocytosis, 144 
Magnesium, basic phosphate of, in 

urine, 165 
Malaria, 196 

cirrhosis due to, 526 

estivo-autumnal type of, 1 97, 202 

etiology of, 197 

parasite of, 198 

pathology of, 199 

quartan type of, 197, 201 

symptomatology of, 200 

tertian type of, 197, 200 
Malarial cachexia, 203, 208 
Malformation, congenital, of heart, 313 

of kidney, 582 
Malignant cachexia, 21 



Malignant edema, bacillus of, 115 

Mallein, 107 

Malposition of kidney, 583 

Malta fever, 311 

Mammary gland, tuberculosis of, 28 1 

Maniacal chorea, 718 

Manus cava, 684 

Marechal's test for bile-pigments in 

urine, 156 
Mark cell, 149 
Marrow cell, 149 
Mast-cell, 149 
McBurney's point, 492 
Measles, 210 

Koplik's sign in, 211 

treatment of, 212 
Measley eruption in typhus fever, 188 
Mediastinal pleurisy, 421 
Mediastinitis, 430 
Mediastinum, abscess of, 431 

diseases of, 430 

inflammation of, 430 

tumors of, 43 2 ,. 433 
Mediate auscultation of voice, 75 

method of auscultation of respiratory 
organs, 66 

percussion, 61 
Medulla, diseases of, 690 

hemorrhage into, 691 
symptoms of, 698 
Megaloblasts, 145 
Mel anuria, color of urine in, 153 
Melasicterus, 30 

Membranes, serous, tuberculosis of, 277 
Membranous croup, 242. See also 

Diphtheria. 
Meniere's disease, 726 
Meningeal hemorrhage, symptoms of, 

698 
Menstruation as a sign in serofibrinous 

pleurisy, 415 
Mensuration of thorax, 60 
'Mercurial poisoning, chronic, 756 
Mercury, stomatitis from, 437 
Metal poisoning, 751 
Metallic rales, 74 

tinkling, 74 
Meteorism, 94 

Metschnikoff 's spirillum, 118 
Microblasts, 145 
Micrococcus melitensis, 121 

tetragenus, 102 
Microcyte, 144 
Microcytosis, 144 
Micro-organisms, 100 

associated with suppuration, IOO 

found in blood, 150 

found in urine, 151 

in sputum, 127 



?88 



INDEX. 



Migraine, 720 
Miliary fever, 288 

treatment of, 289 
Milk-sickness, 290 
Millers' phthisis, 407 
Miners' phthisis, 407 
Mintz' s quantitative test for free hydro- 
chloric acid in stomach-contents, 

.131 

Mitral insufficiency, 330 

regurgitation, 89 

stenosis, 89, 332 

buttonhole mitral valve in, ^33 
physical diagnosis of, 2>33 
Mobius' sign, 644 
Moisture of skin, 36 
Mononuclear cells, 148 
Morbid conditions, influence of, on 

pulse-frequency, 39 
Mountain fever, 290 
Mouth, diseases of, 434 
Mouth-breathing, 444 
Mucous rales, 73, 74 

stools, 168 

vomit, 132 
Midler's blood dust, 150 
Mumps, 261. See also Parotitis. 
Mural endocarditis, 323 
Murexid test for uric acid in urine, 164 
Murmurs, 48 

endocardial, 88 

exocardial, auscultation of, 90 

Flint, in aortic insufficiency, 336 

hemic, 89 

musical, 2>^ 

nuns', 48 

palpable, of heart, 82 

transmission of, in arterial system, 92 

venous, 48 

vesicular, 68 
Muscarin, 745 
Muscles, diseases of, 736 
Mushroom-poisoning, 745 
Musical murmur, 88 
Myalgia, 599 
Myelitis, acute, 670 
treatment of, 672 

chronic, 673 

disseminated, 672 
Myelocytes, 149 
Myocarditis, acute, 352 

chronic interstitial, 353 

general, diagnosis of, 354 
Myocardium, diseases of, 350 

inflammations of, 352, 353 
Myopathic atrophy, 19 
Myositis, 736 

ossificans, 737 
Myospasmia, 719 



Myotonia congenita, 737 
Myxedema, 640 

adult, 640 

operative, 642 



Nasal catarrh, 370, 371 
Neck, stiff, 600 

wry-, 719 
Necrosis, fat, of pancreas, 554 
Nemathelminthes, 763, 768 
Nematodes, 772 

Nephritis, chronic interstitial, 568 
complications of, 57° 
symptoms of, 570 
treatment of, 571 
diffuse, 559 
acute, 558 

diagnosis of, 561 
dropsy in, 561 
pulse in, 561 
symptoms of, 559 

gastric, 561 
treatment of, 561 
urine in, 560 
in scarlet fever, 207 
parenchymatous, 559 
chronic diffuse, 562 
blood in, 566 
changes in circulatory system 

in, 567 
chemic and microscopic con- 
dition of urine in, 566 
complications of, 567 
diagnosis of, differential, 567 
dropsy in, 566 
pathology of, 563 
prognosis of, 567 
symptoms of, eye, 567 

gastric, 566 
treatment of, 567 
urine in, 566 
varieties of, 562 
suppurative, 57 2 
diagnosis of, 575 
symptoms of, 574 
treatment of, 575 
tubular, 559 
Nerve, auditory, diseases of, 657 
cranial, diseases of, 654 
diseases of, 647 
fifth, diseases of, 655 
glossopharyngeal, diseases of, 657 
hypoglossal, diseases of, 658 
ocular, paralysis of, 655 ' 
optic, diseases of, 654 
pneumogastric, diseases of, 657 
seventh, diseases of, 656 
spinal accessory, diseases of, 658 



INDEX. 



789 



Nerve, trifacial, diseases of, 655 

vagus, diseases of, 657 
Nervous system, diseases of, 647 
general and functional, 71 1 
theory of causation of acute rheu- 
matic fever, 238 
Neuralgia, 558 

intercostal, diagnosis of, differential, 
from dry pleurisy, 412 
Neurasthenia, 733-735 
prognosis of, 735 
traumatic, 733 
treatment of, 735 
Neuritis, 647 
brachial, 648 
endemic, 653 
localized, 647 
multiple, 650 

alcoholic variety, 652 
treatment of, 653 
optic, 654 

in tumor of brain, 706 
parenchymatous, 647 
Neuroma of brain, 705 
Neurosis, occupation, 727 

of heart, 356-360. See also Heart, 

neuroses of. 
of secretion, 474 
of stomach, 474 
New-born, jaundice of, t> 2 
Nocturnal epilepsy, 713 
Noma, 438 

Normal percussion, 62. See also Per- 
cussion, normal. 
Normoblasts, 145 
Nose, diseases of, 370 
Nosology, definition of, 18 
Nucleated red corpuscles, 144 
Nun's murmur, 48 
Nutmeg liver, 343, 516, 517 
Nutrition of skin, state of, 27 



Obesity, 19, 609 
Obstipation, 167 
Obstruction of intestines, 495 
Occupation neurosis, 727 
Odor of feces, 168 

of urine, 15 1 
Oligemia, 612 
Oligochromemia, 612 
Oligocythemia, 144, 612 
Oliguria,. 151 

Oliver's hemoglobinometer, 137 
Onychia, syphilitic, 303 
Opisthotonos, 22 

in hysteria, 730 
Optic nerve, diseases of, 654 

neuritis in tumor of brain, 706 



Organic and functional murmur, differ- 
ential diagnosis of, 90 
endocardial murmur, 89 

Orthopnea, 57 

Osteitis deformans, 611 

Osteoarthropathy, hypertrophic, pul- 
monary, 610 

Osteomalacia, 610 

Ox heart in aortic insufficiency, 335 
in chronic pericarditis, 319 

Oxalate of lime crystals in urine, 164 

Oxaluria, 1 64 

Oxyphilic cells, 147, 148 

myelocytes, coarsely granular, 149 

Oxyuris vermicularis, 768 

Ozena, 371 



Pachymeningitis, cervical, hyper- 
trophic, 613 
Pain, connective -tissue, 491 

in abdomen on palpation, 95 

in serous membrane, 491 
Palate, tuberculosis of, 279 
Pallor, 27 
Palpable apex-beat of heart, 82 

murmur, 82 
Palpation in region of thorax, fluctua- 
tion upon, 58 

of abdomen, 94 

of heart, 82 

of liver, 97 

of pulse, 37 

of respiratory organs, 57 
Palpitation, 356 
Palsy, Bell's, 656 

birth, 709 

cerebral, of children, 709 
Pancreas, abscess of, 549 

calculi of, 553 

carcinoma of, 552 

cysts of, 552 

diseases of, 549 

fat necrosis of, 554 

hemorrhage into, 553 

inflammation of, 549 

rupture of, 555 

sarcoma of, 552 

tuberculosis of, 280 

tumors of, 551, 552 
Pancreatitis, 549-551 
Pandemic disease, 18 
Papillitis, 655 

Paracentesis abdominis, 5 1 1 
Paralysis, acute ascending, 675 

agitans, 721 

diphtheric, 246 

divers', 666 

facial, 656 



790 



INDEX. 



Paralysis from lessened atmospheric 
pressure, 666 

muscular pseudohypertrophic, 739 

of ocular nerves, 655 

progressive bulbar, 690 
Paralytic chorea, 718 
Paraplegia, ataxic, 681 
hereditary, 683 

spastic, 680 
Parasites and new growths of heart, 

355 
of pericardium, 323 
animal, diseases due to, 761 
found in blood, 150 
in sputum, 127 
in urine, 163 
in vomit, 133 
of lung, 410 
of malaria, 198 
Parenchymatous degeneration, 351 
Parkinson's disease, 721 
Parotid bubo, 441 
Parotitis, 261, 440 
chronic, 441 
specific, 261 
symptomatic, 441 
symptoms of, 262 
treatment of, 262 
Passive dorsal position in bed, 21 
Pathologic changes in vocal fremitus, 

59 

forms of thorax, 51 
Pathology, definition of, 17 
Patient, constitutional peculiarities of, 
20 

position of, in bed, 21 
in percussion, 62 
Pea- soup stools in typhoid fever, 181 
Pectoral fremitus, 58. See also Vocal 

fremitus. 
Pectoriloquv, whispering, 76 
Pellagra, 683 
Pepsin, test for, in stomach-contents, 

132 
Percussion, abnormal sounds in, 64, 65 

auscultatory, 64 

deep, 64 

degree of resistance in, 64 

methods of, 61, 62 

normal, 62, 63 

objects and aims of, 64 

of abdomen, 95 

of heart, 84 

of liver, 98 

of respiratory organs, 61 

position of patient in, 62 

superficial, 64 

topographic, 64, 99 

use of pleximeter as medium in, 61 



I Percussion, use of plexor in, 62 
! Perforation in typhoid fever, 182 
Pericardial friction sounds, 82, 90 

sounds, 82 

Pericarditis, 314 

acute, 314 

diagnosis of, 317 
physical signs of, 316 
symptoms of, 316 
treatment of, 317 
chronic, 318 

Broadbent's sign in, 320 
diagnosis of, 321 
Friedreich's sign in, 321 
ox heart in, 319 
physical signs of, 319 
symptoms of, 319 
treatment of, 321 
suppurative, 318 
Pericardium, diseases of, 314-360 
friction sounds of, 82, 90 
inflammation of, 314. See also Peri- 
carditis. 
new growths and parasites of, 323 
tuberculosis of, 278 
Perinephritic abscess, 576 
Periodic fevers, 196 
Peristalsis of stomach, 475 
Peristaltic unrest of stomach, 475 
Peritoneal cavity, dropsy of, 20 
Peritoneum, carcinoma of, 513 
cysts of, 514 
diseases of, 504 
sarcoma of, 512 
tuberculosis of, 278 
tumors of, 5 1 2-5 14 
Peritonitis, acute, 504 
treatment of, 509 
adhesive, 508 
chronic, 508 

treatment of, 510 
diaphragmatic, 508 
due to bacteria, 505 
due to chemic irritants, 506 
due to mechanical causes, 506 

diagnosis of, 508 
general, acute, 504 

in typhoid fever, 182 
local, acute, 508 
treatment of, 509 
Perles of Laennec, 126 
Pernicious anemia, 619 
Pertussis, 259 

complications of, 261 
diagnosis of, 261 
etiology of, 260 
treatment of, 261 
Pes cavus, 684 
Pest, 257. See also Plague. 



INDEX. 



791 



Petechia, true, 188 

Petechiae, 34 

Petit mal, 712 

Peyer' s patch, shaven-beard appearance 

of, in typhoid fever, 176 
Phantom corpuscles, 127, 146 

in urine, 160 
. tumor, 94, 732 
Pharyngitis, acute, 445 

chronic, 446 

sicca, 446 
Pharynx, diseases of, 445 
Phlegmonous enteritis, 479 
Phosphaturia, 165 
Phosphorus poisoning, 751 
Phthisical cachexia, 20 
Phthisis, acute pneumonic, 268 

fibroid, 275 

knife-grinders', 407 

millers', 407 

miners', 467 
Phthisoid chest, 21 
Physical diagnosis, 49 

definition of, 18 
Physiology, definition of, 17 
Pia-arachnoid, inflammation of, 693 
Picric acid test for albumin in urine, 155 
Pigeon-breast, 53 
Pigments, bile, in urine, tests for, 156. 

See also Urine, bile pigments in, tests 
for. 
Piles, 500 

Pin-point pupils in hemorrhage into 
medulla and pons, 691 
in locomotor ataxia, 677 
Pin-worm, 768 
Pitch, 61 
Plague, 257 

bacillus of, 119 

diagnosis of, 259 

treatment of, 259 
Plastic pleurisy, 410. See also Pleu- 
risy, dry. 
Plates, blood, 149 
Platyelminth.es, 763 
Pleura, diseases of, 410-430 

echinococcus of, 430 

encapsulated effusions of, 416 

fibroid thickening of, 416 

inflammation of, 410 

resorption of, 416 

tuberculosis of, 277 

tumors of, 429 
Plural exudates, Baccelli sign for, 76 
Pleurisy, 410 

at extremes of age, 421 

atypical forms of, 416 

chronic, 424 

chylous, 420 



Pleurisy, diaphragmatic, 419 
dry, 410 

chronic, 424 

diagnosis of, 412 

treatment of, at extremes of age, 

423 
encapsulated, 421 
encysted, 421 
fibrinous, 410. See also Pleurisy, 

dry. 
hemorrhagic, 420 
interlobular, 421 
mediastinal, 421 
obliteration of Traube's semilunar 

space in, 415 
plastic, 410. See also Pleurisy, dry. 
pulsating, 420 

purulent, 416. See also Empyema. 
serofibrinous, 412-415 

menstruation as a sign in, 415 
special varieties of, 419 
with effusion, 424 

treatment of, at extremes of age, 

423 - 
Pleuritic friction sounds, 75 
Pleurodynia, 600 
Pleuropericardial friction, 75, 91 

in dry pleurisy, 412 
Pleurothotonos, 22 

Pleximeter, use of, as medium in per- 
cussion, 61 
Plexor, 62 
Plug, Dittrich's, 125 
Plumbism, 753 

Pneumococcus, Frankel's, 103 
Pneumogastric nerve, diseases of, 657 
Pneumonia alba, 408 

central, 235 

chronic fibroid, 401 

croupous, 228. See also Croupous 
pneumonia. 
differential diagnosis of, from 
bronchopneumonia, 400 

diplococcus of, in sputum, 127 

Friedlander' s bacillus of, 104 

hypostatic, 404 

in advanced age, 235 

in alcoholics, 235 

in children, 235 

occurring as an intercurrent affection 
in chronic diseases, 286 

typhoid, 235 

white, 408 

with central lesions, 235 

with slight pulmonary lesions, 235 
Pneumonokoniosis, 406 
Pneumopericardium, 322 
Pneumothorax, 425 

diagnosis of, 427 



; 9 2 



INDEX. 



Pneumothorax, treatment of, 427 

Poikiloblasts, 145 

Poikilocyte, 144 

Poikilocytosis, 144 

Poisoning, arsenical, chronic, 757 

by food, 742 

coal-gas, 752 

grain-, 743 

lead-, chronic, 753 

mercurial, chronic, 75^ 

metal, 751 

mushroom-, 745 ■ 

phosphorus, 751, 752 

ptomain-, 742 

silver, chronic, 758 

snake, 745 

treatment of, 747 

water-gas, 752 
Pole-staining, 119 
Poliomyelitis, anterior, acute, 668 
diagnosis of, 670 
treatment of, 670 
Polychromatophilic red corpuscle, 146 
Polymorphonuclear neutrophile, 147 
Polymyositis, acute, 736 
Polynuclear eosinophile, 148 

leukocyte, 147 
Polyuria, 152 
Pons, diseases of, 690 

hemorrhage into, 691 

varolii, hemorrhage into, symptoms 
of, 697 
Pork tapeworm. 764 
Portal vein, diseases of, 546 

inflammation of, 547 
Posthemorrhagic leukocytosis, 147 
Post- typhoid anemia, 181 
Potbelly, 471 
Potassium ferrocyanid and acetic acid 

test for albumin in urine, 155 
Preagonistic rise in fever, 25 
Precritical rise in fever, 25 
Preepileptic insanity, 712 
Primary tumors of lung, 409 
Prior and Finkler, spirillum of, 1 18 
Proctitis, 477 
Prodromes in fever, 24 
Production of apex-beat, 81 
Progressive muscular atrophy, juvenile 

form of, 740 
Prophylaxis, definition of, 17 
Protozoa, 761 
Prune-juice sputum, 233 
Pseudo-angina pectoris, 359^ 
Pseudocrisis in fever, 25 
Pseudodiphtheria, 375 

bacillus of, 1 13 
Pseudohypertrophic emphysema, 390 

muscular paralysis, 739 



Psorospermosis, 76 1 
Psychic epilepsy, 713 
Pterygoid chest, 21, 52 
Ptomain-poisoning, 452, 742 
Ptomains, 742 
Ptyalism, 437, 440 
Puerile respiration, 69 
Pulmonary apoplexy, 396 

atelectasis, 392. See also Atelectasis, 
pulmonary. 

edema, 404 

form of acute miliary tuberculosis, 266 

hemorrhage, 394 
treatment of, 397 

hypertrophic osteoarthropathy, 610 

incompetence, 339 

stenosis, 340 

structure, diseases of, 390-410 
Pulsating aorta, 94 

empyema, 60 

pleurisy, 420 
Pulsation, abnormal, of heart, 77 

epigastric, 92 

expansile, 92 

from aneurysms, 92 

of liver, 97 

of thorax, 60 

visible, 91 
Pulse, 37 

allorrhythmic, 41 

arhythmic, 41 

autochthonous, 47, 48 

capillary, 91 

Corrigan, 42, 335 

dicrotic, 41 

empty, 42 

examination of, 37 

diagnostic value of, 45 

expansion of, 41 

frequency of, 37 

influence of morbid conditions on, 

39 
influence of taking of food on, 38 
full, 42 
hard, 42 
hyperdicrotic, 41 
in acute diffuse nephritis, 561 
irregular, 41, 42 
large, 42 
negative, 47 
normal, 47 
palpation of, 37 
pathologic, 47, 48 
positive, 47, 48 
quality of, 37, 41 
radial, sphygmography of, 43 
rapid, 41. See also Pulsus celer. 
receding, 42, 335 
regular, 42 



INDEX. 



793 



Pulse, rhythm of, 37, 41 

rhythmic, 41 

size of, 41 

slow, 41 

small, 42 

soft, 42 

strength of, 41 

trip-hammer; 42 

venous, 47 
liver, 48 

water-hammer, 42, 335 

wiry, 507 
Pulse-curve, 43, 44 
Pulse-rate, 37 

decrease in, 39 

increase in, 39 
Pulsus alternans, 41 

bigeminus, 41 

celer, 41 

durus, 42 

equalis, 42 

frequens, 39 

inequalis, 42 

intermittens, 41 

magnus, 42 

mollis, 42 

paradoxus, 41 

parvus, 42 

plenus, 42 

rarus, 39 

tardus, 41 

vacuus, 42 
Punctum maximum, 84 
Purpura, 34, 636 

arthritic, 637 

hemorrhagica, 637 

Henoch's, 637 

rheumatica, 637 

simplex, 637 

symptomatic, 636 

variolosa, 216 
Purulent pleurisy, 416. See also Em- 
pyema. 

stools, 169 
Pus in urine, 161 

vomiting, 133 
Putnam and Dana' s combined sclerosis 

of lateral and posterior columns, 

682 
Putrescin, 742 
Pyelitis, 576 

symptoms of, 578 

treatment of, 579 
Pyelonephritis, 576 

symptoms of, 578 

treatment of, 579 
Pyemia, 285 
Pylephlebitis, acute, 547 

adhaesiva, 546 



Pylephlebitis, chronic, 548 
Pyonephrosis, 578 
Pyuria, 161 



Quality of pulse, 37, 41 

of sounds, 61 
Quantitative test for albumin in urine, 

155 
for free hydrochloric acid in stom- 
ach-contents, 131 
Mintz's, 131 
for lactic acid in stomach-contents, 

131 

Quantity of sputum, 123 
Quartan fever, 197, 201 
Quinsy, 443 

Rabies, 307. See also Hydrophobia. 
Rachitic rosary, 601 
Rachitis, 53, 600 
Rales, 73 

crackling, 74 
dry, 73 - 
sibilant, 73 
sonorous, 73 
gurgling, 74 
metallic, 74 
moist, 73 

crepitant, 73, 74 
large mucous, 73 
small mucous, 73, 74 
subcrepitant, 73, 74 
Rattlesnake poisoning, symptoms of, 

746 
Ray fungus, 121 

in sputum, 127 
Raynaud's disease, 724 
Reaction of feces, 168 
of stomach-contents, 129 
of urine, 15 1 
in disease, 15 \ 
Receding pulse, 42 
Recrudescence of temperature, 25 
Red blood-cells in feces, 170 
in urine, 160 
corpuscles, estimation of, 139 

by means of Thoma-Zeiss ap- 
paratus, 139-142 
nucleated, 144 
polychromatophilic, 146 
Red-raspberry excrescence in vaccinia, 

220 
Reduplicated first sound, 81 
Reduplication of heart-sounds, 87 
Regurgitation, aortic, 89 

mitral, 89 
Relapse, 26 

in typhoid fever, 183 



794 



INDEX. 



Relapsing fever, 190 
diagnosis of, 192 
spirillum of, 117 
treatment of, 192 
Remission in temperature, 23 
Remittent fever, infantile, 180, 184 

type of fever, 23, 24 
Renal albuminuria, 154 
calculi, 583 

diagnosis of, 586 
symptoms of, 585 
treatment of, 586 
Rennet, test for, in stomach-contents, 

132 
Resistance, degree of, in percussion, 64 
' determination of, in percussion, 61 
of abdomen in palpation, 94 
Resistant impulse of apex-beat of 

heart, 80 
Resonance, 61, 62 
impaired, 63 
Skodaic, 65 
vocal, 75 
Resorption of the pleura, 416 
Respiration, bronchocavernous, 72 
bronchovesicular, 72 
Cheyne-Stokes, 55 
cog-wheel, 70 
harsh, 72 
jerking, 70 
puerile, 69 
vesiculocavernous, 72 
Respiratory movements, influence of, 
on circulation in veins, 47 
intensity of, 54 
organs, auscultation of, 66 

diseases of, as cause of cyanosis, 29 
examination of, 49 
palpation of, 57 
percussion of, 61 
rhythm, 55 

system, diseases of, 370 
in typhoid fever, 181 
Retraction, systolic, 80 
Retropharyngeal abscess, 446 
Rhabdonema intestinale, 772 
Rheumatic fever, acute, 238 
Rheumatism, cerebral, 240 
chronic, 597 
muscular, 599 
Rhinitis, acute, 370 
atrophic, 371 
chronic, 371 
hypertrophic, 371 
Rhonchi, 59, 60 
in asthma, 59 
in bronchitis, 59, 60 
Rhythm, gallop, 87 

of apex-beat of heart, 81 



Rhythm of heart-sounds, 86 
of pulse, 37, 41 

Rhythmic pulse', 41 

Rice-water discharges, 168 
in cholera, 254 

Rickets, 53, 600 

Ringeri, 767 

Risus sardonicus, 309 4 

Romberg's sign, 677 

Rose fever, 388 

Rosenbach's modification of Gmelin's 
test for bile pigments and bile acids 
in urine, 156 

Roseolar eruptions, t,^ 

Round-worms, 763, 768 

Roy's method for determination of spe- 
cific gravity of blood, Hammer- 
schlag's modification of, 135 

Rubella, 212 

Rubeola, 210 

Rupture of esophagus, 451 
of heart, 355 
of pancreas, 555 

Rusty sputum, 233 



SACCULAR aneurysm, 366 
Salivary glands, diseases of, 440 

inflammations of, 440 
Sanarelli's bacillus, 120 
Sarcoma of brain, 705 
of intestines, 504 
of kidney, 581 
of liver, 536 
of pancreas, 552 
of peritoneum, 512 
of stomach, 469 
Scarlatina anginosa, 208 
latens, 208 
maligna, 208 
simplex, 208 
Scarlet fever, 204 

cat tongue in, 205 
complications of, 207 
diagnosis of, 208 
eruption of, 205 
etiology of, 205 
nephritis in, 207 
symptoms of, 206 
treatment of, 209, 210 
varieties of, 208 
Schonlein's disease, 637 
Schusterbrust, 53 
Sciatica, 649 

Sclerosis, amyotrophic lateral, 684 
disseminated, 686 
multiple, 686 
primary lateral, 680 
spinal posterolateral, 681 



INDEX. 



795 



Scorbutus, 633 
Scrofulous cachexia, 20 
Scurvy, 633 

infantile, 635 
Secondary tumors of lung, 409 
Secretion, neurosis of, 474 
Sediments, urinary, 159. See also 

Urinary sediments. 
Semeiology and symptomatology, 17 

definition of, 18 
Semilunar space, Traube's, 96 

obliteration of, in serofibrinous 
pleurisy, 415 
Sensorium, disturbances of, in tumor of 

brain. 706 
Sepsiri, 742 
Septicemia, 283 
Serofibrinous pleurisy, 412 
Serous vomit, 133 
Seventh nerve, diseases of, 656 
Shadow corpuscles, 127, 146 

in urine, 160 
Shaven-beard appearance of Peyer's 

patch in typhoid fever, 176 
Sibilant rales, 73 
Siderosis, 407 
Signs, definition of. 18 
Silver poisoning, chronic, 758 
Simple continued fever, 17 1 
Simon's triangles, 218 
Skin, blue-red, 27, 29 

bronze, 27, 32 

changes of, in disease, 27 

color of, in disease, 27 

cyanotic, 27, 29 

emphysema of, 35 

examination of, 26 

gray, 27, 32 

hemorrhages under, 34 

icteroid, 27. 30 

in typhoid fever, 182 

jaundice, 27, 30 

livid, 29 

moisture of, 36 

pale, 2^ 

pallor of, 2 7 

red, 27, 28 

secretion of, 36 

state of nutrition of, 27 

yellow, 27, 30 
Skodaic resonance, 65 

in serofibrinous pleurisy, 415 
Slows, 290 
Smallpox, 213 

black, 216 

complications of, 2 1 6 

diagnosis of, 217 

eruption of, 216 

prognosis of, 217 



Smallpox, prophylaxis of, 217 
symptoms of, 214-216 
temperature-curve of, 215 
varieties, 216 
Snake-poison, 745-747 
Soda, urate of, in urine, 164 
Sodium chlorid in blood, 150 

in urine, 166 
Somnolence, 23 
Sonorous rales, 73 
Sopor, 22, 23 
Sore throat, 445 

Sound, abnormal percussion, 64 
characteristics of, 61 
cracked-pot, 65 
friction, 73 

. pleuritic, 75 
in percussion, 61 
Williams' tracheal, 65 
Wintrich's change of, 65 
Spasm, habit-, 718 
of esophagus, 448 
of larynx, 374 
Spasmodic -tics, 718 
Specific gravity of blood, 135 

Hammerschlag' s modification of 
Roy's method for determina- 
tion of, 135 
method of determining, 135 
relation of, to hemoglobin, 135 
of sputum, 124 
of urine in disease, 154 
Spermatozoa in urine, 163 
Sphygmography of radial pulse, 43 
Sphygmopalpation, 37 
Spinal accessory nerve, diseases of, 658 
cord, anemia of, 666 
diseases of, 660 
hemorrhage into, 667 
hyperemia of, 666 
tumors of, 686 
membranes, hemorrhage into, 664 
meningitis, acute, 660 
chronic, 662 
Spiral bodies in sputum, 125 
Spirillum, Metschnikoff 's, 118 
of cholera, 116 
of Finkler and Prior, 118 
of relapsing fever, 117 
Spleen, examination of, 98 

in typhoid fever, 182 
Splenic anemia, 629 

fever, 286 
Splenization of lung tissue in atelectasis, 

393 . 

Sporadic disease, 18 

Spotted fever, 248. See also Cerebro- 
spinal fever. . 

Sputum, animal parasites in, 127 



y 9 6 



INDEX. 



Sputum, bacillus of diphtheria in, 127 
of Friedlander in, 127 
of influenza in, 127 
of tuberculosis in, 105, 127 

bloody, 124 

color of, 124 

crystals in, 126 

diplococcus of pneumonia in, 127 

epithelial cells in, 127 

examination of, 122 
macroscopic, 122 
microscopic, 125 

fibrinous casts in, 125 

forms of consistence of, 123, 124 

in bronchiectasis, 384 

in croupous pneumonia, 233 

micro-organisms in, 127 

mucopurulent, 123 

mucous, 123 

of asthma, 125 

perles of Laennec in, 126 

prune-juice, 233 

purulent, 123 

quantity of, 123 

ray fungus in, 127 

reaction of, 124 

red blood-corpuscles in, 126 

rusty, 233 

serous, 123 

specific gravity of, 124 

spiral bodies in, 125 

white blood-corpuscles in, 126 
St. Anthony's fire, 224. See also Ery- 
sipelas. 
Staccato speech, 664 
Staining, blood, 142, 143 

pole-, 119 
Staphylococcus epidermitis albus, IOI 

pyogenes albus, 100 

aureus, 100 

citreus, 101 

Status epilepticus, 713 

Stell wag's sign, 644 

Stenosis, aortic, 336 

mitral, 89, 332. See also Mitral 
stenosis. 

of aortic orifice, 89 

pulmonary, 340 

tricuspid, 339 
Steppage gait, 651 
Stercoraceous vomiting, 496 
Stethoscope, use of, in auscultation of 
respiratory organs, 66 
of voice, 75 
Stiff neck, 600 
Stomach activity of, 132 

cancer of, 465. See also Stomach, 
carcinoma of. 

carcinoma of, 465 



Stomach, carcinoma of, complications 
of, 469 
diagnosis of, 469 

differential, from gastric ulcer, 
469 
physical signs of, 468 
symptoms of, 467 
treatment of, 469 
deformities of, 471 
dilatation of, 471 
diseases of, 452 
displacements of, 471 
foreign bodies in, 470 
hemorrhage from, 470 
hour-glass, 460 

contraction of, 474 
method of evacuating, 128 
motor power of, 132 
neurosis of," 474 
peristalsis of, 475 
peristaltic unrest of, 475 
physical examination of, 96 
rate of absorption, 132 
sarcoma of, 469 
tuberculosis of, 279 
tumors of, malignant, 465-469 

nonmalignant, 470 
ulcer of, 459 
chronic, 463 
complications of, 461 
course of disease, 463 
diagnosis of, 463 

differential, from gastric cancer, 
469 
prognosis of, 464 
symptoms of, 460 
treatment of, 464 
varieties of, 462 
Stomach-contents, examination of, 128- 
132 
gross appearance of, 129 
Stomatitis, aphthous, 435 
catarrhal, 434 
gangrenous, 438 
mercurial, 437 
parasitic, 436 
ulcerative, 435 
Stones, gall-, in stools, 169 
Stool, bloody, 169 
character of, 168, 169 
fatty, 168 
gall-stones in, 169 
in typhoid fever, 181 
mucous, 168 
purulent, 1 69 
straining at, 167 
Strangulation of intestines, 495 
Strength of vesicular breathing, 68 
murmur, 68 



INDEX. 



797 



Streptococcus conglomeratus, ioi 

pyogenes, ioi 
Stricture of esophagus, 449 

of intestines, 495 
Stupor, 22, 23 

St. Vitus' dance, 717. See also Chorea. 
Subcontinued type of fever, 24 
Subcrepitant rales, 73, 74 
Subcuticular eruption in typhus fever, 

188 
Subnormal temperature, 26 
Subphrenic abscess, 462 
Succussion, 76 

Hippocratic, 76 
Sudamina, 33 

Sulphate of calcium in urine, 165 
Sunstroke, 742, 758 
Supplementary breathing, 69 
Suppuration, micro-organisms asso- 
ciated with, 100 
Suppurative colangitis, 540 
Sutton and Gull's disease, 362. See 

also Arteriosclerosis. 
Sweating, 36 
Swelling, cloudy, 559 
Sydenham' s chorea, 717 
Symptomatology and semeiology, 17 

definition of, 18 
Symptoms, definition of, 18 
Syncope, local, 724 
Syphilis, 300 

acquired, 301 

Colles' law in, 300 

congenital, 303 

of lungs, 407, 408 

vaccinal, 221 

visceral, 304 
Syphilitic cirrhosis, 526 

onychia, 303 
Syringomyelia, 688 
Systolic dimpling, 80 

retraction, 80 



Tabes dorsalis, 676. See also Loco- 
motor ataxia. 

of brain, 679 
Tache bleuatre, 183 

cerebrale in typhoid fever, 183 
Tachycardia, 41, 358 
Tactile fremitus, 58 
Taeniadae, 764 
Taenia echinococcus, 764-767 

lata, 764 

saginata, 764 

solium, 764 
Tapeworms, 763 

beef, 764 

pork, 764 



Tapeworms, symptoms produced by, 7 65 

treatment of, 765 
Temperature, 23 

classification of Wunderlich, 23 

exacerbation in, 23 

in tumor of brain, 707 

in typhoid fever, 179 

inverse fever type, 23 

recrudescence of, 25 

remission in, 23 

subnormal, 26 
Temperature-curve in estivo-autumnal 
fever, 200 

in tertian fever, 200 

in typhoid fever, 180 

in typhus fever, 187 

of croupous pneumonia, 231 

of smallpox, 215 

typical, 25 
Tenesmus, 167, 296 
Terminal leukocytosis, 147 
Tertian fever, 197, 200 

temperature-curve in, 200 
Test for acetic acid in stomach-contents, 

131 
for acetone in urine, 158. See also 

Urine, acetone in, tests for. 
for albumin in urine, 154. See also 

Urine, albumin in, tests for. 
for bile acids in urine, 156. See also 

Urine, bile acids in, tests for. 
for bile pigments in urine, 156. See 

also Urine, bile pigments in, tests 
for. 
for butyric acid in stomach-contents, 

for diacetic acid in urine, 159 

for free hydrochloric acid in stomach- 
contents, 130, 131 

for grape-sugar in urine, 157. See 
also Urine, grape-sitgar in, tests for. 

for lactic acid in stomach-contents, 
130, 131. See also Lactic acid, 
tests for, in stomach-contejits. 

for pepsin in stomach-contents, 132 

for rennet in stomach-contents, 132 

for urea in urine, 166 

for uric acid in urine, murexid, 164 
1 Tetanus, 309 

antitoxin for, 115 

bacillus of, 113, 114 

diagnosis of, 310 

idiopathic, 115 

risus sardonicus in, 309 

treatment of, 310 
The rose, 224. See also Erysipelas. 
Thoma-Zeiss apparatus for counting 
blood-corpuscles, 139 

method, 139-142 



79 8 



INDEX. 



Thomsen's disease, 737 

Thoracic aneurysm, physical signs of, 

368 
Thorax, alar, 52 

barrel chest, 51 

chicken-breast, 53 

emphysematous chest, 51 

expiratory, 5£ 

fluctuation of, upon palpation in 
region of, 58 

funnel-shaped, 53 

Harrison's grooves, 53 

inspiratory, 51 

retraction of intercostal spaces in, 54 

irregular chest, 53 

mensuration of, 60 

paralytic, 52 

pathologic forms of, 51 

phthisical, 52 

pigeon-breast, 53 

pterygoid, 21, 52 

pulsation of, 60 

rachitic, 53 

respiratory type of, 53 

Schusterbrust, 53 

trichterbrust, 53 

unilateral expansion of, 52 
Thread- worm, 768 
Three-day fever, 195 
Thrill, hydatid, 98 
Throat, sore, 445 
Thrombosis, 699 

treatment of, 701 

venous, 48 
Thrush, 436 
Tic douloureux, 659 
Tics, facial, 719 

laryngeal, 719 

spasmodic, 718 
Tissue, shreds of, in feces, 169 
Tongue, diseases of, 439 

tuberculosis of, 279 
Tonsillitis, acute, 441 
follicular, 441 

differential diagnosis of, from 

diphtheria,- 443 
treatment of, 443 

chronic, 444 

suppurative, 443 
Tonsils, diseases of, 441 
Topographic percussion, 64, 99 
Tormina, 296 
Torticollis, 600 
Tracheal breathing, 70 

tugging, 83 
Transportation of viscera, 474 
Traube's semilunar space, 96 

obliteration of, in serofibrinous 
pleurisy, 415 



Trematodes, 767 
Tremors in hysteria, 731 
Trichina spiralis, 769 
Trichinae, 769 
Trichiniasis, 769 

prophylaxis in, 771 

treatment of, 771 
Trichocephalus dispar, 772 
Trichomonas intestinalis, 762 
Trichterbrust, 53 
Tricuspid insufficiency, 338 

stenosis, 339 
Trifacial nerve, diseases of, 655 
Trip-hammer pulse, 42 
Triple phosphate crystals in sputum, 1 26 

in urine, 165 
Trommer's test for grape-sugar in urine, 

157 
Tropeolin test for free hydrochloric acid 

in stomach-contents, 130 
True albuminuria, 154 
aneurysm, 366 
petechia, 188 
Tube, introduction of, for evacuation of 

stomach, 128 
Tubercle, healed, 264 

young, 264 
Tubercular adenitis, local, 277 

lymphadenitis, generalized, 277 
Tuberculin, 106 
Tuberculosis, 262 
acute miliary, 265 

clinical varieties of, 265-268 
differential diagnosis of, from 
enteric fever, 268 
bacillus of, 104 

biologic characteristics of, 106 
in sputum, 127 
chronic ulcerative, 270 
complications of, 274 
diagnosis of, 275 
funnel-breast in, 273 
physical diagnosis of, 273 
signs of cavity in, 274 
symptoms of, 270-273 
Wintrich's sign in, 274 
general miliary, 265 
meningeal, 266-268 
modes of infection, 263 
of alimentary canal, 278 
of arteries, 281 

treatment of, 282, 283 
of brain, 281 
of cord, 281 

of genitourinary system, 2B0 
of heart, 281 

treatment of, 282, 283 
of intestines, 279 
of kidney, 280 



INDEX. 



799 



Tuberculosis of liver, 280 
of lungs, 268 
of lymph -glands, 276 

clinical forms of, 277 
of mammal}- gland, 28 1 
of palate, 279 
of pancreas, 280 
of pericardium, 278 
of peritoneum, 278 
of pleura, 277 
of serous membranes, 277 
of stomach, 279 
of tongue, 279 
pathology of, 264 
pulmonary, 266 
typhoid, 265 
Tugging, tracheal, 83 
Tumors of brain, 705. See also Brain, 

honors of. 
of esophagus, 450 
of intestines, 501 

obstruction due to, 495 
of kidney, 580 
of liver, 534-537. See also Liver, 

tumors of. 
of lung, 409 

of mediastinum, 432, 433 
of pancreas, 551 
of peritoneum, 512-514 
of pleura, 429 
of spinal cord, 688 
of stomach, malignant, 465-469 

nonmalignant, 470 
phantom, 94, 732 
Tympanic sounds, abnormal, in per- 
cussion, 65 
Tvmpany, 61, 63 

'bell, 76 
Typhoid, cholera, 225 
fever, 175 

air-hunger in, 182 

blood in, 181 

Brand's method of treatment, 185 

circulatory system in, 180 

diagnosis of, 184 

differential, from acute miliary 
tuberculosis, 268 

digestive system in, 181 

ducts in, 182 

general peritonitis in, 182 

hemorrhage in, 181, 182 

intercurrent diseases in, 184 

liver in, 182 

perforation in, 182 

prognosis of, 185 

relapse in, 183 

respiratory system in, 181 

sequels of, 184 

skin in, 182 



Typhoid fever, spleen in, 182 

stools in, 181 

symptoms of, 178-182 

tache bleuatre in, 183 

tache cerebral e in, 183 

temperature in, 179 

temperature-curve in, 180 

treatment of, 185, 186 
Brand' s method, 185 

urinary apparatus in, 183 

varieties of, 183 

Widal reaction in, 109 
form of acute miliary tuberculosis, 265 
pneumonia, 235 
Typhus fever, 186 

complications in, 189 

diagnosis of, 189 

eruptions in, 188 

symptoms of, 187, 188 
urinary, 189 

temperature-curve in, 187 

treatment of, 189 
Typical temperature-curve, 25 
Tyrosin in urine, 165 
sheaves in urine, 165 



Uffelmann's test for butyric acid in 
stomach-contents, 131 
for lactic acid in stomach-contents, 

Ulceration, intestinal, 483 
Unorganized casts, 162, 163 

sediments, 163. See also Urinary 
sediments, unorganized. 
Urate of ammonia in urine, 165 
of lime in urine, 164 
of soda in urine, 164 
Urea in urine, 166 
test for, 166 
twenty-four-hour amount of, 151 
Uremia, 150 
acute, 587 

diagnosis of, 588 
chronic, 587 

symptoms of, 588 
treatment of, 588 
Uric acid in urine, 163 

murexid test for, 164 
twenty-four-hour amount of, 151 
Urinary apparatus in typhoid fever, 183 
sediments, 159 

organized, animal parasites, 163 
casts, 161 
epithelium, 159 
leukocytes, 160 
pus, 161 

red blood-cells, 160 
spermatozoa, 163 



8oo 



INDEX. 



Urinary sediments, unorganized, 163 

ammonia-magnesium phosphate, 

165 
basic phosphate of magnesium, 

. l6 5. 
bilirubin crystals, 164 

calcium phosphate, 165 
cholesterin, 166 
cystin, 165 

hematoidin crystals, 164 
leucin, 165 

oxalate of lime crystals, 164 
sodium chlorid, 166 
sulphate of calcium, 165 
triple phosphate, 165 
ty rosin, 165 
urate of ammonia, 165 
of lime, 164 
of soda, 164 
urea, 166 
uric acid, 163 
Urine, acetone in, tests for, 158 
Legal' s, 158 
Lieben's, 158 
acidity of, 154 
albumin in, tests for, 154 

acetic acid and potassium ferro- 

cyanid, 155 
heat and acid, 154 
Heller's, 155 
picric acid, 155 
quantitative, 155 
ammonia-magnesium phosphate in, 

165 
amount secreted, alterations in, 152 

in twenty-four hours, 151 
animal parasites in, 163 
bacteria in, 163 

basic phosphate of magnesium in, 165 
bile adds in, tests for, 156 
MarechaPs, 156 
Rosenbach' s modification of 
Gmelin's, 156 
pigments in, tests for, 156 
Marechal's, 156 
Rosenbach' s modification of 
Gmelin's, 156 
bilirubin crystals in, 164 
blood in, 152 
calcium phosphate in, 165 
casts in, 161 

chemic and microscopic condition of, 
in forms of chronic diffuse paren- 
chymatous nephritis, 566 
cholesterin in, 166 
color of, 151, 152 
in chyluria, 153 
in disease, 152 
in galacturia, 153 



Urine, color of, in hematuria, 152 

in indicanuria, 153 

in melanuria, 153 

influence of drugs on, 153 

normal, 15 1 
cystin in, 165 
diacetic acid in, 158 

test for, 159 
epithelial cells in, 159 
examination of, 15 1 

chemic, 154 
grape-sugar in, 156 

tests for, 157 
Fehling's, 157 
fermentation, 158 
Trommer's, 157 
hematoidin crystals in, 164 
in acute diffuse nephritis, 560 
in croupous pneumonia, 233 
in diabetes mellitus, 593 
leucin in, 165 
leukocytes in, 160 
micro-organisms found in, 157 
odor of, 151 

oxalate of lime crystals in, 164 
phantom corpuscles in, 160 
pus in, 161 
reaction of, 151 

in disease, 154 
red blood-cells in, 160 
shadow corpuscles in, 160 
sodium chlorid in, 166 
specific gravity of, 151 

in disease, 154 
spermatozoa in, 163 
sulphate of calcium in, 165 
triple phosphate in, 165 
tyrosin in, 165 
urate of ammonia in, 165 

of lime in, 164 

of soda in, 164 
urea in, test for, 166 
uric acid in, 163 

murexid test for, 164 



Vaccinal syphilis, 221 
Vaccination, technic of, 221 
Vaccine lymph, 219 
Vaccinia, 219 

complications in, 221 
irregularities of, 220 
red-raspberry excrescence in, 220 
Vagus nerve, diseases of, 657 
Valvular diseases, chronic, prognosis 
of, 340 
treatment of, 341 
effects of, 342 
lesions, combined, 342 



INDEX. 



801 



Varicella, 223 

Variola, 213. See also Smallpox. 

modificata, 217 
Varioloid, 217 
Veins, diastolic collapse of, 48 

examination of, 45 

influence of respiratory movements 
upon circulation in, 47 

murmurs in, 48 
Venous hum, 48 

liver pulse, 48 

murmur, 48 

thrombosis, 48 
Ventricular hemorrhage, symptoms of, 

698 
Verschlusszeit, 81 
Vertigo in tumor of brain, 707 
Vesicular breathing, 67 

with prolonged expiration, 70 

emphysema, 390 

murmur, 68 
Vesiculocavernous respiration, 72 
Vibrion septique, 115 
Vicarious breathing, 69 
Virus, humanized, 222 
Viscera, transportation of, 474 
Visceral crises in locomotor ataxia, 678 

syphilis, 304 
Visceroptosis, 473, 486 
Visible pulsation, 91 
Vocal fremitus, 58, 59 

resonance, 75 
Voice, amphoric, 76 

auscultation of, 75 
Volvulus, 495 
Vomit, 132 

animal parasites in, 133 

bile-stained, 133 

mucous, 132 

serous, 133 
Vomiting, blood, 133 

fecal, 133 

pus, 133" 

stercoraceous, 496 



Von Fleischl's hemoglobinometer, 136 
Von Graefe's sign, 643 



Wandering erysipelas, 226 
liver, 97 

Water-gas poisoning, 752 

Water-hammer pulse, 42, 335 

Water-logged lung in pulmonary edema, 
404 

Weil's disease, 310 

Westphal's sign, 677 

Whip-worm, 772 

Whispering pectoriloquy, 76 

White corpuscles, enumeration of, 142 

Whooping-cough, 259. See also Per- 
tussis. 

Widal reaction, 109 

Williams' tracheal sound, 65 

Wintrich's change of sound, 65 

sign in chronic ulcerative tubercu- 
losis, 274 

Wiry pulse, 507 

Wool-sorter's disease, 286 

Worms, 763 
flat-, 763 
hydatid, 764-767 
pin-, 768 
round, 763, 768 
thread-, 768 
whip-, 772 

Writer's cramp, 727 

Wry -neck, 719 

Wunderlich's classification of tempera- 
ture, 23 

X Bacillus, 121 
Xerostoma, 440 

Yellow fever, 193 
bacillus, 120 
diagnosis of, 194 
treatment of, 194 



51 



CATALOGUE 

OF THE 

MEDICAL PUBLICATIONS 



OF 



W* B. SAUNDERS & CO., 

No. 925 WALNUT STREET, PHILADELPHIA* 



Arranged Alphabetically and Classified under Subjects* 



THE books advertised in this Catalogue as being sold by subscription are usually to be 
obtained from travelling solicitors, but they will be sent direct from the office of pub- 
lication (charges of shipment prepaid) upon receipt of the prices given. All the other 
books advertised are commonly for sale by booksellers in all parts of the United States ; but 
books will be sent to any address, carriage prepaid, on receipt of the published price. 

Money may be sent at the risk of the publisher in either of the following ways : A post- 
office money order, an express money order, a bank check, and in a registered letter. Money 
sent in any other way is at the risk of the sender. 



See pages 32, 33 for a List of Contents classified according to subjects. 

= 5 » 

LATEST PUBLICATIONS. 



American Students' Medical Dictionary* See page 34. 

American Text-Book of Physiology — Second (Revised) Ed* Page?. 

Friedrich and Curtis on Nose. Throat, and Ear. See page 34. 

Le Roy's Histology. See page 34. 

Ogden on the Urine. See page 34. 

Pyle's Personal Hygiene. See page 34. 

Salinger and Kalteyer's Modern Medicine. See page 34. 

Stoney's Surgical Technic for Nurses. See page 34. 

Hyde and Montgomery's Syphilis and Venereal Diseases— Revised 

and Enlarged Edition. See page 15. 
International Text-Book of Surgery. See page J5. 
Garrigues' Diseases of Women — Third (Revised) Edition. Page J3. 
American Text-Book of Dis. of Eye. Ear. Nose, and Throat. Page 5. 
Saunders' American Year-Book for \ 900. See page 8. 
Levy and Klemperer's Clinical Bacteriology. See page 17. 
Scudder's Treatment of Fractures. See page 26. 
Senn's Tumors— Second Edition. See page 27. 
Beck on Fractures. See page 9. 
"Watson's Handbook for Nurses. See page 3 J. 
Heisler's Embryology. See page 15. 
Nancrede's Principles of Surgery. See page 20. 
Jackson's Diseases of the Eye. See page J6. 
Kyle on the Nose and Throat. See page J7. 

Penrose's Diseases of Women — Third (Revised) Edition. Page 20. 
Warren's Surgical Pathology — Second (Revised) Edition. Page 3J. 
Saunder's Medical Hand-Atlases. See pages 2, 3. 4. 
American Pocket Medical Dictionary — Third (Revised) Ed. Page J2. 



SAUNDERS* 

MEDICAL HAND-ATLASES. 



The series of books included under this title consists of authorized 
translations into English of the world-famous Lehmann Medicinische 
Handatlanten, which for scientific accuracy, pictorial beauty, com- 
pactness, and cheapness surpass any similar volumes ever published. 
Each volume contains from 50 to 100 colored plates, executed by the 
most skilful German lithographers, besides numerous illustrations in the 
text. There is a full and appropriate description of each plate, and 
each book contains a condensed but adequate outline of the subject to 
which it is devoted. 

One of the most valuable features of these atlases is that they offer a 
ready and satisfactory substitute for clinical observation. To those 
unable to attend important clinics these books will be absolutely indis- 
pensable. 

In planning this series of books arrangements were made with the rep- 
resentative publishers in the chief medical centers of the world for the 
publication of translations of the atlases into different languages, the litho- 
graphic plates for all these editions being made in Germany, where work of 
this kind has been brought to the greatest perfection. The expense of 
making the plates being shared by the various publishers, the cost to each 
one was materially reduced. Thus by reason of their universal transla- 
tion and reproduction, the publishers have been enabled to secure for these 
atlases the best artistic and professional talent, to produce them in the 
most elegant style, and yet to offer them at a price heretofore unap- 
proached in cheapness. The success of the undertaking is demonstrated 
by the fact that the volumes have already appeared in thirteen different 
languages — German, English, French, Italian, Russian, Spanish, Japanese, 
Dutch, Danish, Swedish, Roumanian, Bohemian, and Hungarian. 

In view of the striking success of these works, Mr. Saunders has con- 
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dred thousand copies of the atlases. In consideration of this enormous 
undertaking, the publisher has been enabled to prepare and furnish special 
additional colored plates, making the series even handsomer and more 
complete than was originally intended. 

As an indication of the practical value of the atlases and of the favor 
with which they have been received, it should be noted that the Medical 
Department of the U.S. Army has adopted the "Atlas of Operative 
Surgery" as its standard, and has ordered the book in "large quantities for 
distribution to the various regiments and army posts. 

The same careful and competent editorial supervision has been 
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SAUNDERS' MEDICAL HAND-ATLASES. 



VOLUMES NOW READY. 
Atlas and Epitome of Internal Medicine and Clinical Diagnosis. 

By Dr. Chr. Jakob, of Erlangen. Edited by Augustus A. Eshner, M.D., 
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Atlas of Legal Medicine. By Dr. E. R. von Hofmann, of Vienna. Edited 

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Atlas and Epitome of Diseases of the Larynx. By Dr. L. Grunwald, 
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Louis Medical and Surgical Journal. 

Atlas and Epitome of Operative Surgery. By Dr. O. Zuckerkandl, 
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" We know of no other work that combines such a wealth of beautiful illustrations with 

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and so useful both for the beginner and for one who wishes to increase his knowledge of 

operative surgery." — Munchener medicinische Wochetischrijt. 

Atlas and Epitome of Syphilis and the Venereal Diseases. By Prof. 
Dr. Franz Mracek, of Vienna. Edited by L. Bolton Bangs, M.D., 
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Medical College, New York. With 71 colored plates, 16 black-and- 
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" A glance through the book is almost like actual attendance upon a famous clinic." — 

Journal oj the American Medical Association. 

Atlas and Epitome of External Diseases of the Eye. By Dr. O. 

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Ophthalmology, Jefferson Medical College, Philadelphia. With 76 

colored illustrations on 40 plates, and 228 pages of text. Cloth, $3.00 net. 

" It is always difficult to represent pathological appearances in colored plates, but this 

work seems to have overcome these difficulties, and the plates, with one or two exceptions, 

are absolutely satisfactory." — Boston Medical and Surgical Journal. 

Atlas and Epitome of Skin Diseases. By Prof. Dr. Franz Mracek, 
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SAUNDERS' MEDICAL HAND-ATLASES. 

VOLUMES JUST ISSUED, 
Atlas and Epitome of Special Pathological Histology. By Dr. H. 

Durck, of Munich. Edited by Ludvig Hektoen, M. D., Professor of 
Pathology, Rush Medical College, Chicago. In Two Parts. Part I. 
Just Ready, including the Circulatory, Respiratory, and Gastro- 
intestinal Tract, with 120 colored figures on 62 plates and 158 pages 
of text. Price, $3.00 net. Parts sold separately. 

Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed. 
Golebiewski, of Berlin. Translated and edited with additions by 
Pearce Bailey, M. D., Attending Physician to the Department of Cor- 
rections, and to the Almshouse and Incurable Hospitals, New York. 
With 40 colored plates, 143 text-illustrations, and 600 pages of text. 

Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of Heidel- 
berg. Edited by Richard C. Norris, A. M., M. D., Gynecologist to 
the Methodist Episcopal and the Philadelphia Hospitals ; Surgeon-in- 
Charge of Preston Retreat, Philadelphia. With 90 colored plates, 65 
text-illustrations, and 308 pages of text. 

IN PRESS FOR EARLY PUBLICATION. 
Atlas and Epitome of Obstetrical Diagnosis and Treatment. By 

Dr. O. Schaffer, of Heidelberg. Edited by J. Clifton Edgar, 
M. D., Professor of Obstretics and Clinical Midwifery, Cornell Univer- 
sity Medical School. 72 colored plates, numerous text-illustrations, 
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Atlas and Epitome of the Nervous System and its Diseases. By 
Prof. Dr. A. von Strumpell, of Erlangen. Edited by Edward D. 
Fisher, M. D., Professor of Diseases of the Nervous System, Univer- 
sity and Bellevue Hospital Medical College, New York. 83 plates and 
a copious text. 

Atlas and Epitome of General Pathological Histology. With an 
Appendix on Pathohistological Technic. By Dr. H. Durck, of 
Munich. Edited by Ludvig Hektoen, M. D., Professor of Path- 
ology, Rush Medical College, Chicago. With 80 colored plates, 
numerous text-illustrations, and copious text. 

IN PREPARATION. 
Atlas and Epitome of Orthopedic Surgery. 
Atlas and Epitome of Operative Gynecology. 
Atlas and Epitome of Diseases of the Ear. 
Atlas and Epitome of General Surgery. 
Atlas and Epitome of Psychiatry. 
Atlas and Epitome of Normal Histology. 
Atlas and Epitome of Topographical Anatomy. 




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AN AMERICAN TEXT=BOOK OF THE DISEASES OF CHILDREN. 
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By 65 Eminent Contributors. Edited by Louis Starr. M. D., Con- 
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AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, 
NOSE, AND THROAT. 

By 58 Prominent Specialists. Edited by G. E. de Schweinitz, M.D., 
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AN AMERICAN TEXT=BOOK OF GENITOURINARY AND SKIN 
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By 47 Eminent Specialists and Teachers. Edited by L. Bolton 
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AN AMERICAN TEXT=BOOK OF GYNECOLOGY, MEDICAL AND 
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By 10 of the Leading Gynecologists of America. Edited by J. M. 
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AN AMERICAN TEXT=BOOK OF LEGAL MEDICINE AND TOXI- 
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Edited by Frederick Peterson, M.D., Clinical Professor of Mental 
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AN AMERICAN TEXT=BOOK OF PATHOLOGY. 

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AN AMERICAN TEXT=BOOK OF THE THEORY AND PRACTICE 
OF MEDICINE. 

By 12 Distinguished American Practitioners. Edited by William 
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8 Medical Publications of W. B. Saunders & Co. 

AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. 

A Yearly Digest of -Scientific Progress and Authoritative Opinion in all 
branches of Medicine and Surgery, drawn from journals, monographs, 
and text-books of the leading American and Foreign authors and 
investigators. Arranged with critical editorial comments, by eminent 
American specialists, under the general editorial charge of George M. 
Gould, M.D. Volumes for 1896, '97, '98, and '99. One imperial 
octavo volume of about 1200 pages. Cloth, $6.50 net; Half Morocco, 
$7.50 net. Year-Book of 1900 in two volumes — Vol. I., including 
General Medici?ie ; Vol. II., General Surgery. Prices per volume: 
Cloth, $3.00 net; Half Morocco, $3.75 net. Sold by Subscription. 

" It is difficult to know which to admire most — the research and industry of the distin- 
guished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or the 
wealth and abundance of the contributions to every department of science that have been 
deemed worthy of analysis. ... It is much more than a mere compilation of abstracts, for, 
as each section is entrusted to experienced and able contributors, the reader has the advant- 
age of certain critical commentaries and expositions . . . proceeding from writers fully 
qualified to perform these tasks. ... It is emphatically a book which should find a place in 
every medical library, and is in several respects more nseful than the famous ' Jahrbucher' 
of Germany." — London Lancet. 

ABBOTT ON TRANSMISSIBLE DISEASES. 

The Hygiene of Transmissible Diseases ; their Causation, 
Modes of Dissemination, and Methods of Prevention. By A. 

C. Abbott, M.D., Professor of Hygiene and Bacteriology, University 
of Pennsylvania ; Director of the Laboratory of Hygiene. Octavo 
volume of 311 pages, containing a number of charts and maps, and 
numerous illustrations. Cloth, $2.00 net. 

THE AMERICAN POCKET MEDICAL DICTIONARY. 

[See D or land 1 s Pocket Dictionary, page 12.] 

ANDERS' PRACTICE OF MEDICINE. Third Revised Edition. 
AText=Book of the Practice of Medicine. By James M. Anders, 
M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of 
Clinical Medicine, Medico- Chirurgical College, Philadelphia. In one 
handsome octavo volume of 1292 pages, fully illustrated. Cloth, 
$5.50 net; Sheep or Half Morocco, $6.50 net. 

*' It is an excellent book, — concise, comprehensive, thorough, and up to date. It is a 
Credit to you ; but, more than that, it is a credit to the profession of Philadelphia — to us." 
J A.MES C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jefferson 
Medical College, Philadelphia. 

ASHTON'S OBSTETRICS. Fourth Edition, Revised. 

Essentials of Obstetrics. By W. Easterly Ashton, M.D., Pro. 
fessor of Gynecology in the Medico-Chirurgical College, Philadelphia. 
Crown octavo, 252 pages; 75 illustrations. Cloth, $1.00 net; inter- 
leaved for notes, $1.25 net. 

[See Saunders' Question- Compends, page 23.] 

" Embodies the whole subject in a nut-shell. We cordially recommend it to our read- 
ers." — Chicago Medical Ti?ues. 



Medical Publications of W. B. Saunders & Co. 



BALL'S BACTERIOLOGY. Third Edition, Revised. 

Essentials of Bacteriology ; a Concise and Systematic Introduction 
to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol- 
ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218 
pages; 82 illustrations, some in colors, and 5 plates. Cloth, $1.00; 
interleaved for notes, $1.25. 

[See Saunders' Question- Compends, page 23.] 

" The student or practitioner can readily obtain a knowledge of the subject from a perusal 
of this book. The illustrations are clear and satisfactory." — Medical Record, New York. 

BASTIN'S BOTANY. 

Laboratory Exercises in Botany. Bv Edson S. Bastin, M.A., 
late Prof, of Materia Medica and Botany, Philadelphia College of Phar- 
macy. Octavo volume of 536 pages, with 87 plates. Cloth, $2.00 net. 

** It is unquestionably the best text-book on the subject that has yet appeared. The 
work is eminently a practical one. We regard the issuance of this book as an important 
event in the history of pharmaceutical teaching in this country, and predict for it an unquali- 
fied success." — Ahwini Report to the Philadelphia College of Pharmacy. 

BECK ON FRACTURES. 

Fractures. By Carl Beck, M.D., Surgeon to St. Mark's Hospital 
and the New York German Poliklinik, etc. 225 pages, 170 illustrations. 
Cloth, $3.50 net. 

BECK'S SURGICAL ASEPSIS. 

A Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to 
St. Mark's Hospital and the New York German Poliklinik, etc. 306 
pages; 65 text-illustrations, and 12 full-page plates. Cloth, $1.25 net. 

" An excellent exposition of the ' very latest ' in the treatment of wounds as practised 
by leading German and American surgeons." — Birmingham (Eng.) Medical Review. 

" This little volume can be recommended to any who are desirous of learning the details 
of asepsis in surgery, for it will serve as a trustworthy guide." — London Lancet. 

BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND 
OPERATIONS. 
Obstetric Accidents, Emergencies, and Operations. By L. Ch. 

Boisliniere, M.D., late Emeritus Professor of Obstetrics, St. Louis 
Medical College. 381 pages, handsomely illustrated. Cloth, $2.00 net. 

" A manual so useful to the student or the general practitioner has not been brought to 
our notice in a long time. The field embraced in the title is covered in a terse, interesting 
way. " — Yale Medical Journal. 

BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. 
Essentials of Medical Physics. By Fred J. Brockway, M.D., 
Assistant Demonstrator of Anatomy in the College of Physicians and 
Surgeons, New York. Crown octavo, 330 pages ; 155 fine illustrations. 
Cloth, $1.00 net ; interleaved for notes, $1.25 net. 

[See Saunders* Question- Comp ends , page 23.] 

"We know of no manual that affords the medical student a better or more concise 
exposition of physics, and the book may be commended as a most satisfactory presentation 
of those essentials that are requisite in a course in medicine." — A T ew York Medical Jownah 



10 Medical Publications of W. B. Saunders & Co. 

BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR- 
MACOLOGY. Third Edition, Revised. 
A Text=Book of Materia Medica, Therapeutics, and Pharma- 
cology. By George F. Butler, Ph.G., M.D., Professor of Materia 
Medica and of Clinical Medicine in the College of Physicians and 
Surgeons, Chicago; Professor of Materia Medica and Therapeutics, 
Northwestern University, Woman's Medical School, etc. Octavo, 874 
pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net. 

" Taken as a whole, the book may fairly be considered as one of the most satisfactory 
of any single-volume works on materia medica in the market," — Journal of the American 
\ Medical Association. 

CERNA ON THE NEWER REMEDIES. Second Edition, Revised. 
Notes on the Newer Remedies, their Therapeutic Applications 
and Modes of Administration. By David Cerna, M.D., Ph.D., 
formerly Demonstrator of and Lecture* on Experimental Therapeutics 
in the University of Pennsylvania ; Demonstrator of Physiology in the 
Medical Department of the University of Texas. Rewritten and 
greatly enlarged. Post-octavo, 253 pages. Cloth, $1. 00 net. 

"The appearance of this new edition of Dr. Cerna's very valuable work shows that it 
is properly appreciated. The book ought to be in the possession of every practising physi- 
cian." — New York Medical Journal. 

CHAPIN ON INSANITY. 

A Compendium of Insanity. By John B. Chapin, M.D., LL.D., 

Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi- 
cian-Superintendent of the Willard State Hospital, New York ; Hon- 
orary Member of the Medico-Psychological Society of Great Britain, 
of the Society of Mental Medicine of Belgium. i2mo, 234 pages, 
illustrated. Cloth, $1.25 net. 

" The practical parts of Dr. Chapin's book are what constitute its distinctive merit. We 
desire especially to call attention to the fact that on the subject of therapeutics of insanity 
the work is exceedingly valuable. It is not a made book, but a genuine condensed thesis, 
which has all the value of ripe opinion and all the charm of a vigorous and natural style." — 
Philadelphia Medical Journal. 

CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. 
Second Edition, Revised. 
Medical Jurisprudence and Toxicology, By Henry C. Chapman, 
M.D., Professor of Institutes of Medicine and Medical Jurisprudence 
in the Jefferson Medical College of Philadelphia. 254 pages, with 55 
illustrations and 3 full-page plates in colors. Cloth, $1.50 net. 
"The best book of its class for the undergraduate that we know of." — New York 
Medical Times. 

CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. 
Second Edition. 
Nervous and Mental Diseases. By Archibald Church, M. D., 
Professor of Clinical Neurology, Mental Diseases, and Medical Juris- 
prudence in the Northwestern University Medical School, Chicago ; 
and Frederick Peterson, M. D., Clinical Professor of Mental Dis- 
eases, Woman's Medical College, N. Y. ; Chief of Clinic, Nervous 
Dept., College of Physicians and Surgeons, N. Y. Handsome octavo 
volume of 843 pages, profusely illustrated. Cloth, $5.00 net; Half 
Morocco, $6.00 net. 



Medical Publications of W. B. Saunders & Co. 11 

CLARKSON'S HISTOLOGY. 

A Text=Book of Histology, Descriptive and Practical. By 

Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of 
Physiology in the Owen's College, Manchester; late Demonstrator of 
Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 
22 engravings in the text, and 174 beautifully colored original illustra- 
tions. Cloth, strongly bound, S4.00 net. 

"The work must be considered a valuable addition to the list of available text- books, 
and is to be highly recommended." — New York Medical Journal. 

"This is one of the best works for students we have ever noticed. "We predict that the 
book will attain a well-deserved popularity among our students." — Chicago Medical Recorder. 

CLIMATOLOGY. 

Transactions of the Eighth Annual Meeting of the American 
Climatological Association, held in Washington, September 22-25, 
1891. Forming a handsome octavo volume of 276 pages, uniform with 
remainder of series. (A limited quantity only.) Cloth, $1.50. 

COHEN AND ESHNER'S DIAGNOSIS. Second Edition, Revised. 
Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- 
fessor of Clinical Medicine and Applied Therapeutics in the Philadel- 
phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical 
Medicine in the Philadelphia Polyclinic. Post-octavo, 417 pages; 55 
illustrations. Cloth, $1.00 net. 

[See Saunders* Question- Compends, page 23.] 

"We can heartily commend the book to all those who contemplate purchasing a 'com- 
pend.' It is modern and complete, and will give more satisfaction than many other works 
which are perhaps too prolix as well as behind the times." — Medical Review, St. Louis. 

CORWIN'S PHYSICAL DIAGNOSIS. Third Edition, Revised. 

Essentials of Physical Diagnosis of the Thorax. By Arthur 
M. Corwin, A.M., M.D., Demonstrator of Physical Diagnosis in Rush 
Medical College, Chicago ; Attending Physician to Central Free Dis- 
pensary, Department of Rhinology, Laryngology, and Diseases of the 
Chest, Chicago. 219 pages, illustrated. Cloth, flexible covers, $1.25 net. 

"It is excellent. The student who shall use it as his guide to the careful study of 
physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good 
working knowledge of the subject." — Philadelphia Polyclinic. 

"A most excellent little work. It brightens the memory of the differential diagnostic 
signs, and it arranges orderly and in sequence the various objective phenomena to logical 
solution of a careful diagnosis." — Journal of Nervous and Mental Diseases. 

CRAGIN'S GYNAECOLOGY. Fourth Edition, Revised. 

Essentials of Gynaecology. By Edwin B. Cragin, M. D., Lecturer 
in Obstetrics, College of Physicians and Surgeons, New York. Crown 
octavo, 200 pages; 62 illustrations. Cloth, Si. 00 net; interleaved for 
notes, Si. 25 net. 

[See Saunders'' Question- Compends, page 23.] 

" A handy volume, and a distinct improvement on students' compends in general. No 
author who was not himself a practical gynecologist could have consulted the student's needs 
so thoroughly as Dr. Cragin has done." — Medical Record, New York. 



12 Meaical Publications of W. B. Saunders & Co. 

CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised. 

A Text=Book of Bacteriology. By Edgar M. Crookshank, M.B., 
Professor of Comparative Pathology and Bacteriology, King's College, 
London. Octavo volume of 700 pages, with 273 engravings and 22 
original colored plates. Cloth, $6.50 net; Half Morocco, $7.50 net. 

" To the student who wishes to' obtain a good resume of what has been done in bacteri- 
ology, or who wishes an accurate account of the various methods of research, the book may 
be recommended with confidence that he will find there what he requires." — London Lancet. 

Da COSTA'S SURGERY. Second Ed., Revised and Greatly Enlarged. 
Modern Surgery, General and Operative. By John Chalmers 
DaCosta, M. D., Professor of Practice of Surgery and Clinical Surgery, 
Jefferson Medical College, Philadelphia ; Surgeon to the Philadelphia 
Hospital, etc. Handsome octavo volume of 911 pages, profusely illus- 
trated. Cloth, $4.00 net; Half Morocco, $5.00 net. 

"We know of no small work on surgery in the English language which so well fulfils 
the requirements of the modern student." — Medico- Chirurgical Journal, Bristol, England. 

DE SCHWEINITZ ON DISEASES OF THE EYE. Third Edition, 
Revised. 
Diseases of the Eye. A Handbook of Ophthalmic Practice. 

By G. E. de Schweinitz, M.D., Professor of Ophthalmology in the 
Jefferson Medical College, Philadelphia, etc. Handsome royal octavo 
volume of 696 pages, with 256 fine illustrations and 2 chromo-litho- 
graphic plates. Cloth, $4.00 net ; Sheep or Half Morocco, $5.00 net. 

" A clearly written, comprehensive manual. One which we can commend to students 
as a reliable text-book, written with an evident knowledge of the wants of those entering 
upon the study of this special branch of medical science." — British Medical Journal. 

" A work that will meet the requirements not only of the specialist, but of the general 
practitioner in a rare degree. I am satisfied that unusual success awaits it." — William 
Pepper, M.D., Professor of the Theory and Practice of Medicine and Clinical Medicine, 
University of Pennsylvania. 

DORLAND'S DICTIONARY. Third Edition, Revised. 

The American Pocket Medical Dictionary. Containing the Pro- 
nunciation and Definition of all the principal words and phrases, and a 
large number of useful tables. Edited by W. A. Newman Borland, 
M. D., Assistant Demonstrator of Obstetrics, University of Pennsylvania; 
Fellow of the American Academy of Medicine. 518 pages ; handsomely 
bound in full leather, limp, with gilt edges and patent index. Price, 
$1.00 net; with thumb index, $1.25 net. 

DORLAND'S OBSTETRICS. 

A Manual of Obstetrics. By W. A. Newman Dorland, M.D., 
Assistant Demonstrator of Obstetrics, University of Pennsylvania; 
Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages; 
163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net. 

" By far the best book on this subject that has ever come to our notice." — American 
Medical Review. 

" It has rarely been our duty to review a book which has given us more pleasure in its 
perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge, 
a gold mine of practical, concise thoughts." — Atnerican Medico- Surgical Bulletin. 



Medical Publications of W. B. Saunders & Co, 13 

PROTHINGHAM'S GUIDE FOR THE BACTERIOLOGIST. 

Laboratory Guide for the Bacteriologist. By Langdon Froth- 
ingham, M.D.V. , Assistant in Bacteriology and Veterinary Science, 
Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts. 

" It is a convenient and useful little work, and will more than repay the outlay neces- 
sary for its purchase in the saving of time which would otherwise be consumed in looking 
up the various points of technique so clearly and concisely laid down in its pages." — Ameri- 
can Medico- Surgical Bulletin. 

GARRIGUES' DISEASES OF WOMEN. Third Edition, Revised. 
Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro- 
fessor of Gynecology in the New York School of Clinical Medicine ; 
Gynecologist to St. Mark's Hospital and to the German Dispensary, 
New York City, etc. Handsome octavo volume of 783 pages, illus- 
trated by 367 engravings and colored plates. Cloth, $4.00 net; 
Sheep or Half Morocco, $5.00 net. 

' ' One of the best text-books for students and practitioners which has been published in 
the English language ; it is condensed, clear, and comprehensive. The profound learning 
and great clinical experience of the distinguished author find expression in this book in a 
most attractive and instructive form. Young practitioners to whom experienced consultants 
may not be available will find in this book invaluable counsel and help." — Thad. A. 
REAMY, M.D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio. 

GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. 
Essentials of Diseases of the Ear. By E. B. Gleason, S.B., 
M.D., Clinical Professor of Otology, Medico-Chirurgical College, 
Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- 
ment of the Northern Dispensary, Philadelphia. 208 pages, with 114 
illustrations. Cloth, $1.00 net ; interleaved for notes, $1.25 net. 

[See Saunders' Question- Campe7ids i page 23.] 

" It is just the book to put into the hands of a student, and cannot fail to give him a 
useful introduction to ear- affections ; while the style of question and answer which is adopted 
throughout the book is, we believe, the best method of impressing facts permanently on the 
mind. " — Liverpool Medico- Chiruigical Journal. 

GOULD AND PYLE'S CURIOSITIES OF MEDICINE. 

Anomalies and Curiosities of Medicine. Bv George M. Gould, 
M.D., and Walter L. Pyle, M.D. An encyclopedic collection of 
rare and extraordinary cases and of the most striking instances of 
abnormality in all branches of Medicine and Surgery, derived from an 
exhaustive research of medical literature from its origin to the present 
day, abstracted, classified, annotated, and indexed. Handsome im- 
perial octavo volume of 968 pages, with 295 engravings in the text, 
and 12 full-page plates. 

POPULAR EDITION: Cloth, $3.00 net; Half Morocco, $4.00 net. 

" One of the most valuable contributions ever made to medical literature. Ii. is, so far 
as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for 
the medical profession has this volume value : it will serve as a book of reference for all who 
are interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical 
Journal. 

"This is certainly a most remarkable and interesting volume. It stands alone among 
medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in 
medical literature. It is a book full of revelations from its first to its last page, and cannot 
but interest and sometimes almost horrify its readers." — American Medico- Surgical Bulletin. 



14 Medical Publications of W. B. Saunders & Co. 

GRAFSTROM'S MECHANOTHERAPY. 

A Text=Book of Mechanotherapy (Massage and Medical Gym= 
nasties). By Axel V. Grafstrom, B. Sc, M. D., late Lieutenant in 
the Royal Swedish Army ; late House Physician City Hospital, Black- 
well's Island, New York. i2mo. 139 pages, illustrated. Cloth, $1. 00 net. 

GRIFFITH ON THE BABY. Second Edition, Revised. 

The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini- 
cal Professor of Diseases of Children, University of Pennsylvania ; 
Physician to the Children's Hospital, Philadelphia, etc. 121110, 404 
pages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50 net. 

" The best book for the use of the young mother with which we are acquainted. . . . 
There are very few general practitioners who could not read the book through with advan- 
tage. ' ' — Archives of Pediatrics. 

"The whole book is characterized by rare good sense, and is evidently written by a 
master hand. It can be read with benefit not only by mothers but by medical students and 
by any practitioners who have not had large opportunities for observing children." — Ameri- 
can Journal of Obstetrics. 

GRIFFITH'S WEIGHT CHART. 

Infant's Weight Chart. Designed by J. P. Crozer Griffith, M.D., 
Clinical Professor of Diseases of Children in the University of Penn- 
sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. 

GROSS, SAMUEL D., AUTOBIOGRAPHY OF. 

Autobiography of Samuel D. Gross, M. D., Emeritus Professor of 
Surgery in the Jefferson Medical College, Philadelphia, with Remi- 
niscences of His Times and Contemporaries. Edited by his Sons, 
Samuel W. Gross, M.D., LL.D., and A. Haller Gross, A.M. Pre- 
ceded by a Memoir of Dr. Gross, by the late Austin Flint, M.D. 
Two handsome volumes, over 400 pages each, demy octavo, gilt tops, 
with Frontispiece on steel. Price per volume, $2.50 net. 

HAMPTON'S NURSING. Second Edition, Revised and Enlarged. 
Nursing: Its Principles and Practice. By Isabel Adams Hamp 
ton, Graduate of the New York Training School for Nurses attached 
to Bellevue Hospital ; late Superintendent of Nurses and Principal of 
the Training School for Nurses, Johns Hopkins Hospital, Baltimore, 
Md. 12 mo, 512 pages, illustrated. Cloth, $2.00 net. 

" Seldom have we perused a book upon the subject that has given us so much pleasure 
as the one before us. We would strongly urge upon the members of our own profession the 
need of a book like this, for it will enable each of us to become a training school in him- 
self." — Ontario Medical Journal. 

HARE'S PHYSIOLOGY. Fourth Edition, Revised. 

Essentials of Physiology. By H. A. Hare, M.D., Professor of 
Therapeutics and Materia Medica in the Jefferson Medical College of 
Philadelphia. Crown octavo, 239 pages. Cloth, #1.00 net; inter- 
leaved for notes, #1.25 net. 

[See Saunders' Question- Compends, page 23.] 

" The best condensation of physiological knowledge we have yet seen." — Medical 
Record, New York. 



Medical Publications of W. B. Saunders & Co. 15 

HART'S DIET IN SICKNESS AND IN HEALTH. 

Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly 
Student of the Faculty of Medicine of Paris and of the London School 
of Medicine for Women ; with an Introduction by Sir Henry 
Thompson, F.R.C.S., M.D., London. 220 pages. Cloth, #1.50 net. 

" We recommend it cordially to the attention of all practitioners ; both to them and to 
their patients it may be of the greatest service." — New York Medical Journal. 

HAYNES' ANATOMY. 

A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct 
Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- 
ment of the New York University, etc. 680 pages, illustrated with 42 
diagrams in the text, and 134 full-page half-tone illustrations from 
original photographs of the author's dissections. Cloth, $2.50 net. 

" This book is the work of a practical instructor — one who knows by experience the 
requirements of the average student, and is able to meet these requirements in a very satis- 
factory way. The book is one that can be commended." — Medical Record, New York. 

HEISLER'S EMBRYOLOGY. 

A Text=Book of Embryology. By John C. Heisler, M.D., Pro- 
fessor of Anatomy in the Medico-Chirnrgicat College, Philadelphia. Oc- 
tavo volume of 405 pages, handsomely illustrated. Cloth, $2.50 net. 

HIRST'S OBSTETRICS. Second Edition. 

A Text=Book of Obstetrics. By Barton Cooke Hirst, M. D., 
Professor of Obstetrics in the University of Pennsylvania. Handsome 
octavo volume of 848 pages, with 618 illustrations, and 7 colored 
plates. Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net. 

" The illustrations are numerous and are works of art, many of them appearing for the 
first time. The arrangement of the subject-matter, the foot-notes, and index are beyond 
criticism. As a true model of what a modern text-book on obstetrics should be, we feel 
justified in affirming that Dr. Hirst's book is without a rival." — New York Medical Record. 

HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL 
DISEASES. Second Edition, Revised and Enlarged. 
Syphilis and the Venereal Diseases. By James Nevins Hyde, 
M. D., Professor of Skin and Venereal Diseases, and Frank H. Mont- 
gomery, M. D., Lecturer on Dermatology and Genito-Urinary Diseases 
in Rush Medical College, Chicago, 111. Octavo, nearly 600 pages, with 
14 beautiful lithographic plates and numerous illustrations. 

" We can commend this manual to the student as a help to him in his study of venereal 
diseases. ' ' — Liverpool Medico- Chirurgical Journal. 

"The best student's manual which has appeared on the subject." — St. Louis Medical 
and Surgical Journal. 

INTERNATIONAL TEXT=BOOK OF SURGERY. In two volumes. 
By American and British authors. Edited by J. Collins Warren, 
M.D., LL.D., Professor of Surgery, Harvard Medical School, Boston; 
and A. Pearce Gould, M.S., F.R.C.S., Lecturer on Practical Sur- 
gery and Teacher of Operative Surgery, Middlesex Hospital Medical 
School, London, Eng. Vol. I. General Surgery. — Handsome octavo, 
947 pages, with 458 beautiful illustrations and 9 lithographic plates. 
Vol. II. Special or Regional Surgery. — Handsome octavo, 1072 pages, 
with 471 beautiful illustrations and 8 lithographic plates. Prices per 
volume: Cloth, $5.00 net; Half Morocco, $6.00 net. 



16 Medical Publications of W. B. Saunders & Co. 

JACKSON'S DISEASES OF THE EYE. 

A Manual of Diseases of the Eye. By Edward Jackson, A.M., 
M.D., sometime Professor of Diseases of the Eye in the Philadelphia 
Polyclinic and College for Graduates in Medicine, nrao volume of 
535 P a g es > witn i7 8 beautiful illustrations, mostly from drawings by the 
author. Cloth, $2.50 net. 

JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND 
THROAT. Second Edition, Revised. 
Essentials of Refraction and Diseases of the Eye. By Edward 
Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- 
delphia Polyclinic and College for Graduates in Medicine ; and — 
Essentials of Diseases of the Nose and Throat. By E. Bald- 
win Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and 
Ear Department of the Northern Dispensary of Philadelphia. Two 
volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, 
#1.00 net; interleaved for notes, $1.25 net. 

[See Saunders'' Question- Compends, page 22.] 

" Of great value to the beginner in these branches. The authors are both capable men, 
and know what a student most needs." — Medical Record, New York. 

KEATING'S DICTIONARY. Second Edition, Revised. 

A New Pronouncing Dictionary of Medicine, with Phonetic 
Pronunciation, Accentuation, Etymology, etc. By John M. 
Keating, M.D., LL.D., Fellow of the College of Physicians of Phila- 
delphia, and Henry Hamilton ; with the collaboration of J. Chal- 
mers DaCosta, M.D., and Frederick A. Packard, M.D. With an 
Appendix containi g Tables of Bacilli, Micrococci, Leucomaines, 
Ptomaines, etc. One volume of over 800 pages. Prices, with Ready- 
Refereixce Index: Cloth, $5.00 net; Sheep or Half Morocco, $6.00 
net. Without Patent Index : Cloth, $4.00 net ; Sheep or Half Morocco, 
$5.00- net. 

"I am much pleased with Keating's Dictionary, and shall take pleasure in recommend- 
ing it to my classes." — Henry M. Lyman, M. D., Professor of the Principles and Practice 
vf Medicine, Rush Medical College, Chicago, III. 

KEATING'S LIFE INSURANCE. 

How to Examine for Life Insurance. By John M. Keating, 
M. D., Fellow of the College of Physicians of Philadelphia; Vice- 
President of the American Pediatric Society; Ex-President of the 
Association of Life Insurance Medical Directors. Royal octavo, 211 
pages ; with two large half-tone illustrations, and a plate prepared by 
Dr. McClellan from special dissections ; also, numerous other illustra- 
tions. Cloth, $2.00 net. 

KEEN'S OPERATION BLANK. Second Edition, Revised Form. 
An Operation B!*nk, with Lists of Instruments, etc., Required 
in Various Operations. Prepared by W. W. Keen, M.D., LL.D., 
Professor of the Principles of Surgery in Jefferson Medical College, 
Philadelphia. Price per pad, blanks for fifty operations, 50 cents net. 



Medical Publications of W. B. Saunders & Co. 17 

KEEN ON THE SURGERY OF TYPHOID FEVER. 

The Surgical Complications and Sequels of Typhoid Fever 

By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur- 
gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; 
Corresponding Member of the Societe de Chirurgie, Paris ; Honorary 
Member of the Societe Beige de Chirurgie, etc. Octavo volume of 
$86 pages, illustrated. Cloth, $3.00 net. 

" This is probably the first and only work in the English language that gives the reader 
a clear view of what typhoid fever really is, and what it does and can do to the human 
organism. This book should be in the possession of every medical man in America." — 
American Medico-Surgical Bulletin. 

KYLE ON THE NOSE AND THROAT. 

Diseases of the Nose and Throat. By D. Braden Kyle, M.D., 
Clinical Professor of Laryngology and Rhinology, Jefferson Medical 
College, Philadelphia; Consulting Laryngologist, Rhinologist, and 
Otologist, St. Agnes' Hospital. Handsome octavo volume of about 
630 pages, with over 150 illustrations and 6 lithographic plates. Price, 
Cloth, $4.00 net ; Half Morocco, $5.00 net. 

LAINE'S TEMPERATURE CHART. 

Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x 13^ 
inches. A conveniently arranged Chart for recording Temperature^ 
with columns for daily amounts of Urinary and Fecal Excretions, 
Food, Remarks, etc. On the back of each chart is given in full the 
method of Brand in the treatment of Typhoid Fever. Price, per pad 
of 25 charts, 50 cents net. 

" To the busy practitioner this chart will be found of great value in fever cases, and 
especially for cases of typhoid." — Indian Lancet, Calcutta. 

LEVY AND KLE/VIPERER'S CLINICAL BACTERIOLOGY. 

The Elements of Clinical Bacteriology. By Dr. Ernst Levy, Profes- 
sor in the University of Strassburg, and Felix Klemperer, Privat docent 
in the University of Strassburg. Translated and edited by Augustus 
A. Eshner, M.D'., Professor of Clinical Medicine in the Philadelphia 
Polyclinic. Octavo, 440 pages, fully illustrated. Cloth, #2.. 50 net. 

LOCKWOOD'S PRACTICE OF MEDICINE. 

A Manual of the Practice of Medicine. By George Roe Lock- 
wood, M.D., Professor of Practice in the Woman's Medical College 
of the New York Infirmary, etc. 935 pages, with 75 illustrations in 
the text, and 22 full-page plates. Cloth, $2.50 net. 

" Gives in a most concise manner the points essential to treatment usually enumeratec 
in the most elaborate works." — Massachusetts Medical Journal. 

LONG'S SYLLABUS OF GYNECOLOGY. 

A Syllabus of Gynecology, arranged in Conformity with «« An 
American Text=Book of Gynecology." By J. W. Long, M.D., 
Professor of Diseases of Women and Children, Medical College of 
Virginia, etc. Cloth, interleaved, $1.00 net. 

" The book is certainly an admirable resume of what every gynecological student and 
practitioner should kmow, and will prove of value not only to those who have the ' Americar 
Text-Book of Gynecology,' but to others as well." — Brooklyn Medical Journal. 



18 Medical Publications of W. B. Saunders & Co. 

MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. 

Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. 
Edin., F.R.C.S., Edin., Professor of the Practice of Surgery and of 
Clinical Surgery in Hamline University ; Visiting Surgeon to St. 
Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 
800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, 
$6. co net. 

" A thorough and complete work on surgical diagnosis and treatment, free from pad- 
ding, full of valuable material, and in accord with the surgical teaching of the day." — The 

Medical News, New York. 

" The work is brimful of just the kind of practical information that is useful alike to 
students and practitioners. It is a pleasure to commend the bock because of its intrinsic 
valuo to the medical practitioner." — Cincinnati Lancet-Clinic 

MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. 

Pathological Technique. A Practical Manual for Laboratory Work 
in Pathology, Bacteriology, and Morbid Anatomy, with chapters on 
Post-Mortem Technique and the Performance of Autopsies. By Frank 
B. Mallory, A.M., M.D., Assistant Professor of Pathology, Harvard 
University Medical School, Boston; and James H. Wright, A.M., 
M.D., Instructor in Pathology, Harvard University Medical School. 
Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth, 
$2.50 net. 

" I have been looking forward to the publication of this book, and I am gi.ld to say that 
I find it to be a most useful laboratory and post-mortem guide, full of practical information, 
and v/ell up to date." — Willi AM H. Welch, Professor of Pathology, Johns Hopkins Uni- 
versity, Baltimore, Aid. 

MARTIN'S MINOR SURGERY, BANDAGING, AND VENEREAL 
DISEASES. Second Edition, Revised. 
Essentials of Minor Surgery, Bandaging, and Venoreal 
Diseases. By Edward Martin, A.M., M.D., Clinical Professor of 
Genito-Urinary Diseases, University of Pennsylvania, etc. Crown 
octavo, 166 pages, with 78 illustrations. Cloth, $1.00 net; interleaved 
for notes, #1.25 net. 

[See Saunders' Question- Compends, page 23.] 

"A very practical and systematic study of the subjects, and shows the author's famil- 
iarity with the needs of students." — Therapeutic Gazette. 

MARTIN'S SURGERY. Seventh Edition, Revised. 

Essentials of Surgery. Containing also Venereal Diseases, Surgi- 
cal Landmarks, Minor and Operative Surgery, and a complete de- 
scription, with illustrations, of the Handkerchief and Roller Bandages. 
By Edward Martin, A.M., M.D., Clinical Professor of Genito- 
Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 342 
pages, illustrated. With an Appendix on the preparation of the materials 
used in Antiseptic Surgery, etc., and a chapter on Appendicitis. Cloth, 
$1.00 net; interleaved for notes, $1.25 net 

[See Saunders'' Question- Compends, page 23.] 

" Contains all necessary essentials of modern surgery in a comparatively small space. 
Its style is interesting, and its illustrations are admirable." — Medical and Surgical Reporter, 



Medical Publications of W. B. Saunders & Co. 19 



McFARLAND'S PATHOGENIC BACTERIA. Second Edition, Re- 
vised and Greatly Enlarged. 
Text=Book upon the Pathogenic Bacteria. By Joseph McFar- 
land, M. D., Professor of Pathology and Bacteriology in the Medico- 
Chirurgical College of Philadelphia, etc. Octavo volume of 497 pages, 
finely illustrated. Cloth, $2.50 net. 

" Dr. McFarland has treated the subject in a systematic manner, and has succeeded in 
presenting in a concise and readable form the essentials of bacteriology up to date. Alto- 
gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the 
students of Trinity College." — H. B. Anderson, M.D. , Professor of Pathology and Bac- 
teriology, Trinity Medical College, Toronto. 

MEIGS ON FEEDING IN INFANCY. 

Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound 
in limp cloth, flush edges, 25 cents net. 

"This pamphlet is worth many times over its price to the physician. The author's 
experiments and conclusions are original, and have been the means of doing much good." — 
Medical Bulletin. 

MOORE'S ORTHOPEDIC SURGERY. 

A Manual of Orthopedic Surgery. By James E. Moore, M.D., 
Professor of Orthopedics and Adjunct Professor of Clinical Surgery, 
University of Minnesota, College of Medicine and Surgery. Octavo 
volume of 356 pages, handsomely illustrated. Cloth, $2.50 net. 

"A most attractive work. The illustrations and the care with which the book is adapted 
to the wants of the general practitioner and the student are worthy of great praise." — Chicago 
Medical Recorder. 

" A very demonstrative work, every illustration of which conveys a lesson. The work is 
a most excellent and commendable one, which we can certainly endorse with pleasure." — 
St. Louis Medical and Surgical Journal. 

MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fifth 
Edition, Revised. 
Essentials of Materia Medica, Therapeutics, and Prescription- 
Writing. By Henry Morris, M.D., late Demonstrator of Thera- 
peutics, Jefferson Medical College, Philadelphia; Fellow of the College 
of Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth, 
$1.00 net; interleaved for notes, $1.25 net. 

[See Saunders 1 Question- Compends, page 22.] 

" This work, already excellent in the old edition, has been largely improved by revi- 
sion. " — American Practitioner and News. 

MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE. 
Third Edition, Revised. 
Essentials of the Practice of Medicine. By Henry Morris, M.D. ? 
late Demonstrator of Therapeutics, Jefferson Medical College, Phila* 
delphia; with an Appendix on the Clinical and Microscopic Examina- 
tion of Urine, by Lawrence Wolff, M.D. , Demonstrator of Chemistry, 
Jefferson Medical College, Philadelphia. Enlarged by some 300 essen- 
tial formulae collected and arranged by William M. Powell, M.D. 
Post-octavo, 488 pages. Cloth, $1.50 net. 

[See Saunders'' Question- Compends, page 22.] 

" The teaching is sound, the presentation graphic ; matter full as can be desired, anri 
style attractive." — American Practitioner and News. 



20 Medical Publications of W. B. Saunders & Co. 

MORTEN'S NURSES DICTIONARY. 

Nurse's Dictionary of Medical Terms and Nursing Treat- 
ment. Containing Definitions of the Principal Medical and Nursing 
Terms and Abbreviations ; of the Instruments, Drugs, Diseases, Acci- 
dents, Treatments, Operations, Foods, Appliances, etc. encountered 
in the ward or in the sick-room. By Honnor Morten, author of 
" How to Become a Nurse," etc. 161110, 140 pages. Cloth, $1.00 net. 

" A handy, compact little volume, containing a large amount of general information, all 
of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference. 
It is certainly of value to those for whose use it is published." — Chicago Clinical Review. 

NANCREDE'S ANATOMY. Sixth Edition, Thoroughly Revised. 
Essentials of Anatomy, including the Anatomy of the Viscera. 

By Charles B. Nancrede, M.D., LL.D., Professor of Surgery and 
of Clinical Surgery in the University of Michigan, Ann Arbor. Crown 
octavo, 420 pages; 151 illustrations. Based upon Gray's Anatomy. 
Cloth, #1.00 net; interleaved for notes, $1.25 net. 

[See Saunders 1 Question- Compends, page 23.] 

" For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at 
school, it would not be easy to speak of it in terms too favorable." — American Practitioner. 

NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition. 
Essentials of Anatomy and Manual of Practical Dissection. 

By Charles B. Nancrede, M.D., LL.D., Professor of Surgery and of 
Clinical Surgery, University of Michigan, Ann Arbor. Post-octavo ; 
500 pages, with full-page lithographic plates in colors, and nearly 200 
illustrations. Extra Cloth (or Oilcloth for dissection-room), $2.00 net. 

" It may in many respects be considered an epitome of Gray's popular work on general 
anatomy, at the same time having some distinguishing characteristics of its own to commend 
it The plates are of more than ordinary excellence, and are of especial value to students 
in their work in the dissecting room." — Journal of the American Medical Association. 

NANCREDE'S PRINCIPLES OF SURGERY. 

Lectures on the Principles of Surgery. By Chas. B. Nancrede, 
M.D., LL.D., Professor of Surgery and of Clinical Surgery, Univer- 
sity of Michigan, Ann Arbor. Octavo volume of 398 pages, illustrated. 
Cloth, $2.50 net. 

NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised, 
Syllabus of Obstetrical Lectures in the Medical Department 
of the University of Pennsylvania. By Richard C. Norris, 
A.M., M.D., Demonstrator of Obstetrics. University of Pennsylvania. 
Crown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net. 

PENROSE'S DISEASES OF WOMEN. Third Edition, Revised. 
A Text=Book of Diseases of Women. By Charles B. Penrose, 
M. D., Ph.D., Formerly Professor of Gynecology in the University 
of Pennsylvania; Surgeon to the Gynecean Hospital, Philadelphia. 
Octavo volume of 531 pages, handsomely illustrated. Cloth, $3.75 net. 

"I shall value very highly the copy of Penrose's 'Diseases of Women' received. 
I have already recommended it to my class as THE BEST book."— Howard A. Kelly, 

Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md. . 



Medical Publications of W. B. Saunders & Co. 21 

POWELL'S DISEASES OF CHILDREN. Second Edition. 

Essentials of Diseases of Children. By William M. Powell, 
M.D., Attending Physician to the Mercer House for Invalid Women 
at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of 
Children in the Hospital of the University of Pennsylvania. Crown 
octavo, 222 pages. Cloth, $i.oonet; interleaved for notes, #1.25 net. 

[See Saunders' Question- Compends, page 21.] 

" Contains the gist of all the best works in the department to which it relates."— - 
American Practitioner and News. 

PRINGLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS. 
Pictorial Atlas of Skin Diseases and Syphilitic Affections 
(American Edition). Translation from the French. Edited by 
J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex 
Hospital, London. Photo-lithochromes from the famous models in 
the Museum of the Saint-Louis Hospital, Paris, with explanatory wood- 
cuts and text. In 12 Parts. Price per Part, $3.00. Complete in 
one volume, Half Morocco binding, $40.00 net. 

" I strongly recommend this Atlas. The plates are exceedingly well executed, and 
will be of great value to all studying dermatology." — Sterhen Mackenzie, M.D. 

"The introduction of explanatory wood-cuts in the text is a novel and most important 
feature which greatly furthers the easier understanding of the excellent plates, than which 
nothing, we venture to say, has been seen better in point of correctness, beauty, and general 
merit." — New York Medical Journal. 

PRYOR— PELVIC INFLAMMATIONS. 

The Treatment of Pelvic Inflammations through the Vagina. 

By W. R. Pryor, M.D., Professor of Gynecology in New York Poly- 
clinic. i2ino, 248 pages, handsomely illustrated. Cloth, $2.00 net. 

" This subject, which has recently been so thoroughly canvassed in high gynecological 
circles, is made available in this volume to the general practitioner and student. Nothing is 
too minute for mention and nothing is taken for granted ; consequently the book is of the utmost 
value. The illustrations and the technique are beyond criticism." — Chicago Medical Recorder. 

PYE'S BANDAGING. 

Elementary Bandaging and Surgical Dressing. With Direc- 
tions concerning the Immediate Treatment of Cases of Emergency. 
For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late 
Surgeon to St. Mary's Hospital, London. Small 121110, with over 80 
illustrations. Cloth, flexible covers, 75 cents net. 
"The directions are clear and the illustrations are good." — London Lancet. 
" The author writes well, the diagrams are clear, and the book itself is small and port- 
able, although the paper and type are good." — British Medical Journal. 

RAYMOND'S PHYSIOLOGY. 

A Manual of Physiology. By Joseph H. Raymond, A.M., M.D., 
Professor of Physiology and Hygiene and Lecturer on Gynecology in 
the Long Island College Hospital ; Director of Physiology in the 
Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the 
text, and 4 full-page colored plates. Cloth, #1.25 net. 

" Extremely well gotten up, and the illustrations have been selected with care. The 
text is fully abreast with modern physiology." — British Medical Journal. 




I 

SAUNDERS* Arranged in Question and 

_^ Answer Form, 

V^ U E.U 1 IVJi N qpHE MOST COMPLETE AND BEST 

r^OftTTOClVrnC ILLUSTRATED SERIES OF 

V^VJIVIJKCInIJO COMPENDS EVER ISSUED. 

Now the Standard Authorities in Medical Literature 

with. Students and Practitioners in every City of the United States and Canada* 



o>- 



OVER 175,000 COPIES SOLD. ^ 



THE REASON WHY. 

They are the advance guard of "Student's Helps" — that do help. They are the 
leaders in their special line, well and authoritatively written by able men, who, as teachers in 
the large colleges, know exactly what is wanted by a student preparing for his examinations. 
The judgment exercised in the selection of authors is fully demonstrated by their professional 
standing. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of 
them have become Professors and Lecturers in their respective colleges. 

Each book is of convenient size (5x7 inches) , containing on an average 250 pages, 
profusely illustrated, and elegantly printed in clear, readable type, on fine paper. 

The entire series, numbering twenty-three volumes, has been kept thoroughly revised 
and enlarged when necessary, many of the books being in their fifth and sixth editions. 

TO SUM UP. 

Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of 
them approach the " Blue Series of Question Compends;" and the claim is made for the 
following points of excellence : 

1. Professional distinction and reputation of authors. 

2. Conciseness, clearness, and soundness of treatment. 

3. Quality of illustrations, paper, printing, and binding. 

Any cf these Compends will be mailed on receipt of price (see next page for List). 



Saunders' Question-Compend Series* 

Price, Cloth, $L00 net per copy, except when otherwise ordered. 



"Where the work of preparing students' manuals is to end we cannot say, but the 
Saunders Series, in our opinion, bears off the palm at present."— New York Medical Record. 



1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Fourth edition, 

revised and enlarged. 

2. ESSENTIALS OF SURGERY. By Edward Martin, M. D. Seventh edition, 

revised, with an Appendix and a chapter on Appendicitis. 

3. ESSENTIALS OF ANATOMY. By Chart.es B. Nancrede, M.D. Sixth 

edition, thoroughly revised and enlarged. 

4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 

By Lawrence Wolff, M.D. Fifth edition, revised. 

5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth 

edition, revised and enlarged. 

6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. 

Armand Semple, M.D. 

7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- 

SCRIPTION=WRITING. By Henry Morris, M.D. Fifth edition, revised. 

8,9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, 
M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. 
Third edition, enlarged by some 300 Essential Formulae, selected from eminent 
authorities, by Wm. M. Powell, M.D. (Double number, #1.50 net.) 

10. ESSENTIALS OF GYNECOLOGY. By Edwin B. Cragin, M.D. Fourth 

edition, revised. 

11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, 

M.D. Fourth edition, revised and enlarged. 

12. ESSENTIALS OF MINOR SURGERY, BANDAGiNG, AND VENEREAL 

DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 

13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 

By C. E. Armand Semple, M.D. 

14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 

By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 

15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, 

M.D. Second edition. 

16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, 

M.D. Colored " Vogel Scale." (75 cents net.) 

17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, 

M.D. Second edition, thoroughly revised. 

18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. 

Second edition, revised and enlarged. 

20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition, 

revised. 

21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. 

Shaw, M.D. Third edition, revised. 

22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D. 

Second edition, revised. 

23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D., 

and Edward S. Law t rance, M.D. 

24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D. 

Second edition, revised and greatly enlarged. 



Pamphlet containing specimen pages, etc. sent free upon application. 




Saunders" , Ct , 

tor otudents 

New Series and 

of Manuals Practitioners< 



** I 'HAT there exists a need for thoroughly reliable hand-books on the leading branches 
of Medicine and Surgery is a fact amply demonstrated by the favor with which 
the SAUNDERS NEW SERIES OF MANUALS have been received by medical 
students and practitioners and by the Medical Press, These manuals are not merely 
condensations from present literature, but are ably written by well-known authors 
and practitioners, most of them being teachers in representative American colleges. 
Each volume is concisely and authoritatively written and exhaustive in detail, without 
being encumbered with the introduction of "cases," which so largely expand the 
ordinary text-book. These manuals will therefore form an admirable collection of 
advanced lectures, useful alike to the medical student and the practitioner: to the 
latter, too busy to search through page after page of elaborate treatises for what he 
wants to know, they will prove of inestimable value ; to the former they will afford 
safe guides to the essential points of study. 

The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior 
to any similar books now on the market. No other manuals afford so much infor- 
mation in such a concise and available form. A liberal expenditure has enabled the 
publisher to render the mechanical portion of the work worthy of the high literary 
standard attained by these books. 

Any of these Manuals will be mailed on receipt of price (see next page for List). 



Saunders' New Series of Manuals* 



VOLUMES PUBLISHED. 

PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology 
and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; 
Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, $1.25 neu 

SURGERY, General and Operative.— By John Chalmers DaCosta, M. D., Pro- 
fessor of Practice of Surgery and Clinical Surgery, Jefferson Medical College, Philadel- 
phia; Surgeon to the Philadelphia Hospital, etc. Second edition, thoroughly revised 
and greatly enlarged. Octavo, 91 1 pages, profusely illustrated. Cloth, $4.00 net; 
Half Morocco, S5.00 net. 

DOSE=BOOK AND MANUAL OF PRESCRIPTION=WRITING. By E. Q. 

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
delphia. Illustrated. Cloth, Si. 25 net. 

SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and 
to the New York German Poliklinik, etc. Illustrated. Cloth, $1.25 net. 

MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- 
tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- 
delphia. Illustrated. Cloth. Si. 50 net. 

SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D., 
Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D., 
Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College., 
Chicago. Second edition, thoroughly revised and greatly enlarged. 

PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of 
Practice in the Woman's Medical College of the New York Infirmary; Instructor in 
Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated. 
Cloth, $2. 50 net. 

MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of 
Anatomy and Demonstrator of Anatomy, Medical Department of the Ne"w York 
University, etc. Beautifully illustrated. Cloth, $2.50 net. 

MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant 
Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis- 
pensary, Pennsylvania Hospital, etc. Profusely illustrated. Cloth, $2.50 net. 

DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to 
Middlesex Hospital and Surgeon to Chelsea Hospital, London; and Arthur E. 
Giles, M. D., B. Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, 
London. Handsomely illustrated. Cloth, S2.50 net. 



VOLUMES IN PREPARATION. 

NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous 
Diseases, Medico-Chirurgical College, Philadelphia ; Pathologist to the Orthopaedic 
Hospital and Infirmary for Nervous Diseases ; Visiting Physician to the St. Joseph 
Hospital, etc. 

*** There will be published in the same series, at short intervals, carefully-prepared work* 
on various subjects by prominent specialists. 



Pamphlet containing specimen pages, etc. sent free upon application. 



28 Medical Publications of W. B. Saunders & Co. 

SAUNDBY'S RENAL AND URINARY DISEASES. 

Lectures on Renal and Urinary Diseases. By Robert Saundby, 
M.D. Edin., Fellow of the Royal College of Physicians, London, and 
of the Royal Medico-Chirurgical Society ; Physician to the General 
Hospital ; Consulting Physician to the Eye Hospital and to the Hos- 
pital for Diseases of Women; Professor of Medicine in Mason College, 
Birmingham, etc. Octavo volume of 434 pages, with numerous illus- 
trations and 4 colored plates. Cloth, $2.50 net. 

" The volume makes a favorable impression at once. The style is clear and succinct. 
We cannot find any part of the subject in which the views expressed are not carefully thought 
out and fortified by evidence drawn from the most recent sources. The book may be cordially 
recommended.' ' — British Medical Journal. 

SAUNDERS' MEDICAL HAND=ATLASES. 

For full description of this series, with list of volumes and prices, see 
page 2. 

" Lehmann Medicinische Handatlanten belong to that class of books that are too good 
to be appropriated by any one nation." — Journal of Eye, Ear, and Throat Diseases. 

" The appearance of these works marks a new era in illustrated English medical 
works." — The Canadian Practitioner. 

SAUNDERS' POCKET MEDICAL FORMULARY. Sixth Edition, 
Revised. 

By William M. Powell, M.D., Attending Physician to the Mercer 
House for Invalid Women at Atlantic City, N. J. Containing 1800 
formulae selected from the best-known authorities. With an Appen- 
dix containing Posological Table, Formulae and Doses for Hypo- 
dermic Medication, Poisons and their Antidotes, Diameters of the 
Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various 
Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment 
of Asphyxia from Drowning, Surgical Remembrancer, Tables of 
Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- 
somely bound in flexible morocco, with side index, wallet, and flap. 
#1.75 net. 

" This little book, that can be conveniently carried in the pocket, contains an immense 
amount of material. It is very useful, and, as the name of the author of each prescription 
is given, is unusually reliable." — Medical Record, New York. 

SAYRE'S PHARMACY. Second Edition, Revised. 

Essentials of the Practice of Pharmacy. By Lucius E. Sayre, 
M.D., Professor of Pharmacy and Materia Medica in the University of 
Kansas. Crown octavo, 200 pages. Cloth, $1.00 net ; interleavec for 
notes, $1.25 net. 

[See Saunders' Question- Compends, page 21.] 

'* The topics are treated in a simple, practical manner, and the work forms a very usefui 
student's manual." — Boston Medical and Surgical Journal. 

SCUDDER'S FRACTURES. 

The Treatment of Fractures. By Chas. L. Scudder, M.D., As- 
sistant in Clinical and Operative Surgery, Harvard Medical School. 
Octavo, 433 pages, with nearly 600 original illustrations. Cloth, $4.50 
net. 



Medical Publications of W. B. Saunders & Co, 27 

SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 

Essentials of Legal Medicine, Toxicology, and Hygiene. By 

C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond., 
Physician to the Northeastern Hospital for Children, Hackney, etc. 
Crown octavo, 212 pages; 130 illustrations. Cloth, $1.00 net; inter- 
leaved for notes, $1.25 net. 

[See Saunders' Question- Compends, page 21.] 

" No general practitioner or student can afford to be without this valuable work. The 
subjects are dealt with by a masterly hand." — London Hospital Gazette. 

SEMPLE'S PATHOLOGY AND MORBID ANATOMY. 

Essentials of Pathology and Morbid Anatomy. By C. E. 

Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to 
the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 174 
pages; illustrated. Cloth, $1.00 net; interleaved for notes, $1.25 n^t. 

[See Saunders 1 Question- Comfie?ids, page 21.] 

" Should take its place among the standard volumes on the bookshelf of both student 
and practitioner."— Londo?i Hospital Gazette. 

SENN'S GENITOURINARY TUBERCULOSIS. 

Tuberculosis of the Genito=Urinary Organs, Male and Female. 

By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of 
Surgery and of Clinical Surgery, Rush Medical College, Chicago, 
Handsome octavo volume of 320 pages, illustrated. Cloth, $3.00 net. 

" An important book upon an important subject, and written by a man of mature judg- 
ment and wide experience. The author has given us an instructive book upon one of the 
most important subjects of the day." — Clinical Reporter. 

" A work which adds another to the many obligations the profession owes the talented 
author. " — Chicago Medical Recorder. 

SENN'S SYLLABUS OF SURGERY. 

A Syllabus of Lectures on the Practice of Surgery, arranged 
in conformity with " An American Text=Book of Surgery." By 

Nicholas Seen, M. D., Ph.D., Professor of the Practice of Surgery and 
of Clinical Surgery, Rush Medical College, Chicago. Cloth, Si. 50 net. 

" This syllabus will be found of service by the teacher as well as the student, the work 
being superbly done. There is no praise too high for it. No surgeon should be without 
it. " — New York Medical Times. 

SENN'S TUMORS. Second Edition, Revised. 

Pathology and Surgical Treatment of Tumors. By N. Senn, 
M.D, Ph.D., LL.D., Professor of Surgery and of Clinical Surgery, 
Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; 
Attending Surgeon to Presbyterian Hospital ; Surgeon-in- Chief, St. 
Joseph's Hospital, Chicago. Second Edition, Thoroughly Revised. Oc- 
tavo volume of 718 pages, with 478 illustrations, including 12 full-page 
plates in colors. Prices: Cloth, 55.00 net: Half Morocco, $6.00 net. 

" The most exhaustive of any recent book in English on this subject. It is well illus- 
trated, and will doubtless remain as the principal monograph on the subject in our language 
for some years. The book is handsomely illustrated and printed, and the author has given 3 
notable and lasting contribution to surgery." — Journal of the American Medical Association. 



28 Medical Publications of W. B. Saunders & Co. 

SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, 
Revised. 
Essentials of Nervous Diseases and Insanity. By John C. 
Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous 
System, Long Island College Hospital Medical School ; Consulting 
Neurologist to St. Catherine's Hospital and to the Long Island College 
Hospital. Crown octavo, 186 pages; 48 original illustrations. Cloth, 
1 1. 00 net; interleaved for notes, $1.25 net. 

[See Saunders' Question- Compends, page 21.] 
" Clearly and intelligently written." — Boston Medical and Surgical Journal. 

"There is a mass of valuable material crowded into this small compass. 1 ' — American 
Medico- Surgical Bulletin. 

STARR'S DIETS FOR INFANTS AND CHILDREN. 

Diets for Infants and Children in Health and in Disease. By 

Louis Starr, M.D., Editor of ''An American Text-Book of the 
Diseases of Children." 230 blanks (pocket-book size), perforated 
and neatly bound in flexible morocco. $1.25 net. 

The first series of blanks are prepared for the first seven months of infant life ; each 
Mank indicates the ingredients, but not the quantities, of the food, the latter directions being 
left for the physician. After the seventh month, modifications being less necessary, the diet 
lists are printed in full. Formulae for the preparation of diluents and foods are appended. 

STELWAGON'S DISEASES OF THE SKIN. Fourth Ed., Revised. 
Essentials of Diseases of the Skin. By Henry W. Stelwagon, 
M.D., Clinical Professor of Dermatology in the Jefferson MedicaL 
College, Philadelphia ; Dermatologist to the Philadelphia Hospital ; 
Physician to the Skin Department of the Howard Hospital, etc. 
Crown octavo, 276 pages; 88 illustrations. Cloth, |i.oonet; inter- 
leaved for notes, $1.25 net. 

[See Saunders' Question- Compends, page 21.] 
" The best student's manual on skin diseases we have yet seen." — Times and Register^ 

STENGEL'S PATHOLOGY. Second Edition. 

A Text=Book of Pathology. By Alfred Stengel, M.D., Professor 
of Clinical Medicine in the University of Pennsylvania ; Physician to 
the Philadelphia Hospital ; Physician to the Children's Hospital, etc. 
Handsome octavo volume of 848 pages, with nearly 400 illustrations, 
many of them in colors. Cloth, $4.00 net; Half Morocco, $5.00 
net. 

STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second 
Edition, Revised. 
A Manual of Materia Medica and Therapeutics. By A. A. 

Stevens, A.M., M.D., Lecturer on Terminology and Instructor in 
Physical Diagnosis in the University of Pennsylvania; Professor of 
Pathology in the Woman's Medical College of Pennsylvania. Post- 
octavo, 445 pages. Flexible leather, $2.00 net. 
"The author has faithfully presented modern therapeutics in a comprehensive work, 
and, while intended particularly for the use of students, it will be found a reliable guide and 
sufficiently comprehensive for the physician in practice."— University Medical Magazine. 



Medical Publications of W. B. Saunders & Co. 29 

STEVENS' PRACTICE OF MEDICINE. Fifth Edition, Revised. 
A Manual of the Practice of Medicine. By A. A. Stevens, A. M., 
M. D., Lecturer on Terminology and Instructor in Physical Diagnosis 
in the University of Pennsylvania ; Professor of Pathology in the 
Woman's Medical College of Pennsylvania. Specially intended for 
students preparing for graduation and hospital examinations. Post- 
octavo, 519 pages; illustrated. Flexible leather, $2.00 net. 

" The frequency with which new editions of this manual are demanded bespeaks its 
popularity. It is an excellent condensation of the essentials of medical practice for the 
student, and maybe found also an excellent reminder for the busy physician." — Buffalo 
Medical Journal. 

STEWART'S PHYSIOLOGY. Third Edition, Revised. 

A Manual of Physiology, with Practical Exercises. For 
Students and Practitioners. By G. N. Stewart, M.A., M.D., 
D.Sc, lately Examiner in Physiology, University of Aberdeen, and 
of the New Museums, Cambridge University ; Professor of Physiology 
in the Western Reserve University, Cleveland, Ohio. Octavo volume 
of 848 pages; 300 illustrations in the text, and 5 colored plates. 
Cloth, $3.75 net. 

" It will make its way by sheer force of merit, and amply deserves tc do so. It is one 
of the very best English text-books on the subject." — London Lancet. 

1 'Of the many text-books of physiology published, we do not know of one that so 
nearly comes up to the ideal as does Prof. Stewart's volume."- — British Medical Journal. 

STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. 

Essentials of Medical Electricity. By D. D. Stewart, M.D., 
Demonstrator of Diseases of the Nervous System and Chief of the 
Neurological Clinic in the Jefferson Medical College ; and E. S. 
Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- 
' strator of Diseases of the Nervous System in the Jefferson Medical 
College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, 
$1.00 net; interleaved for notes, $1.25 net. 

[See Saunders" Question- Compends, page 21.] 

" Throughout the whole brief space at their command the authors show a discriminating 
knowledge of their subject." — Medical News. 

STONEY'S NURSING. Second Edition, Revised. 

Practical Points in Nursing. For Nurses in Private Practice, 

By Emily A. M. Stoney, Graduate of the Training-School for Nurses, 
Lawrence, Mass.; late Superintendent of the Training-School for 
Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated 
with 73 engravings in the text, and 8 colored and half-tone plates. 
Cloth, $1.75 net. 

" There are few books intended for non-professional readers which can be so cordially 
endorsed by a medical journal as can this one." — Therapeutic Gazette. 

" This is a well-written, eminently practical volume, which covers the entire range of 
private nursing as distinguished from hospital nursing, and instructs the nurse how best to 
meet the various emergencies which may arise, and how to prepare everything ordinarily 
needed in the illness of her patient." — American Journal oj Obstetrics and Diseases of 
Women and Children. 

" It is a work that the physician can place in the hands of his private nurses with thf 
assurance of benefit." — Ohio Medical Journal. 



30 Medical Publications of W. B. Saunders & Co. 

STONEY'S MATERIA MEDICA FOR NURSES. 

Materia Medica for Nurses. By Emily A. M. Stoney, Graduate of 
the Training-School for Nurses, Lawrence, Mass. ; late Superintendent 
of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 
Handsome octavo volume of 306 pages. Cloth, $1.50 net. 

The present book differs from other similar works in several features, all of which are 
intended to render it more practical and generally useful. The general plan of the contents 
lollows the lines laid down in training-schools for nurses, but the book contains much use- 
ful matter not usually included in works of this character, such as Poison-emergencies, 
Ready Dose-list, Weights and Measures, etc., as well as a Glossary, defining all the terms 
used in Materia Medica, and describing all the latest drugs and remedies, which have been 
generally neglected by other books of the kind. 

SUTTON AND GILES' DISEASES OF WOMEN. 

Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant 
Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, 
London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., 
Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- 
somely illustrated. Cloth, $2.50 net. 

"The text has been carefully prepared. Nothing essential has been omitted, and its 
teachings are those recommended by the leading authorities of the day r .' : '—Journal of the 
American Medical Association. 

THOMAS'S DIET LISTS. Second Edition, Revised. 

Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, 
M.D., Visiting Physician to the Home for Friendless Women and 
Children and to the Newsboys' Home; Assistant Visiting Physician 'to 
the Kings County Hospital. Cloth, $1.25 net. Send for sample sheet. 

THORNTON'S DOSE=BOOK AND PRESCRIPTION=WRITING. 

Dose=Book and Manual of Prescription=Writing. By E. Q. 

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical 
College, Philadelphia. 334 pages, illustrated. Cloth, #1.25 net. 

"Full of practical suggestions; will take its place in the front rank of works of this 
sort." — Medical Record, New York. 

VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. 
Diseases of the Stomach. By William W. Van Valzah, M.D., 
Professor of General Medicine and Diseases of the Digestive System 
and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D., 
Adjunct Professor of General Medicine and Diseases of the Digestive 
System and the Blood, New York Polyclinic. Octavo volume of 674 
pages, illustrated. Cloth, $3.50 net. 

" Its chief claim lies in its clearness and general adaptability to the practical needs of 
the general practitioner or student. In these relations it is probably the best of the recent 
special works on diseases of the stomach." — Chicago Clinical Review. 

VECKI'S SEXUAL IMPOTENCE. 

The Pathology and Treatment of Sexual Impotence. By Victor 
G. Vecki, M.D. From the second German edition, revised and en- 
larged. Demi-octavo, 291 pages. Cloth, #2.-60 net. 

The subject of impotence has seldom been treated in this country in the truly scientific 
spirit that it deserves. Dr. Vecki's work has long been favorably known, and the German 
8X)ok has received the highest consideration. This edition is more than a mere translation, 
tor, although based on the German edition, it has been entirely rewritten in English. 



Medical Publications of W. B. Saunders & Co. 31 

VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised. 
Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- 
cine at the University of Heidelberg. Translated, with additions, 
from the fifth enlarged German edition, with the author's permission, 
by Francis H. Stuart, A. M., M. D. Handsome royal octavo volume 
of 603 pages; 194 fine wood-cuts in text, many of them in colors. 
Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. 

" Rarely is a book published with which a reviewer can find so little fault as with the 
volume before us. Each particular item in the consideration of an organ or apparatus, which 
is necessary to determine a diagnosis of any disease of that organ, is mentioned ; nothing 
seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and 
nervous system are especially full and valuable. The reviewer would repeat that the book is 
one of the best — probably the best — which has fallen into his hands." — University Medical 
Magazine. 

WATSON'S HANDBOOK FOR NURSES. 

A Handbook for Nurses. By J. K. Watson, M.D., Edin. Ameri- 
can Edition, under supervision of A. A. Stevens, A.M., M.D., Lecturer 
on Physical Diagnosis, University of Pennsylvania. i2mo, 413 pages, 
73 illustrations. Cloth, $1.50 net. 

WARREN'S SURGICAL PATHOLOGY. Second Edition. 

Surgical Pathology and Therapeutics. By John Collins Warren, 
M.D., LL.D., Professor of Surgery, Harvard Medical School. Hand- 
some octavo, 832 pages : 136 relief and lithographic illustrations, $$ in 
colors ; with an Appendix on Scientific Aids to Surgical Diagnosis, and 
a series of articles on Regional Bacteriology. Cloth, $5.00 net; Half 
Morocco, $6.00 net. 

"A most striking and very excellent feature of this book is its illustrations. Without 
exception, from the point of accuracy and artistic merit, they are the best ever seen in a work 
of this kind. Many of those representing microscopic pictures are so perfect in their coloring 
and detail as almost to give the beholder the impression that he is looking down the barrel 
of a microscope at a well-mounted section." — Annals of Stirgery. 

WOLFF ON EXAMINATION OF URINE. 

Essentials of Examination of Urine. By Lawrence Wolff, M.D., 
Demonstrator of Chemistry, Jefferson Medical College, Philadelphia] 
etc. Colored (Vogel) urine scale and numerous illustrations. Crown 
octavo. Cloth, 75 cents net. 

[See Saunders' Question- Compends, page 21.] 
" A very good work of its kind— very well suited to its purpose." — Times and Register. 

WOLFF'S MEDICAL CHEMISTRY. Fifth Edition, Revised. 

Essentials of Medical Chemistry, Organic and Inorganic. 

Containing also Questions on Medical Physics, Chemical Physiology, 
Analytical Processes, Urinalysis, and Toxicology. By Lawrence 
Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, 
Philadelphia, etc. Crown octavo, 222 pages. Cloth, $1.00 net; inter- 
leaved for notes, $1.25 net. 

[See Saunders' Question- Compends, page 21.] 

"The scope of this work is certainly equal to that of the best course of lectures on 
Medical Chemistry." — Pharmaceutical Era. 



CLASSIFIED LIST 



Medical Publications 



W. B. SAUNDERS & COMPANY, 

925 Walnut Street, Philadelphia. 



ANATOMY, EMBRYOLOGY, 
HISTOLOGY. 

Clarkson — A Text-Book of Histology, 1 1 

Haynes — A Manual of Anatomy, . . . 15 

Heisler — A Text- Book of Embryology, 15 

Nancrede — Essentials of Anatomy, . . 20 
Nancrede — Essentials of Anatomy and 

Manual of Practical Dissection, ... 20 

Semple — Essentials of Pathology, . . 27 

BACTERIOLOGY. 

Ball — Essentials of Bacteriology, ... 8 
Crookshank — A Text- Book of Bacteri- 
ology, 12 

Frothingham— Laboratory Guide, . . 13 
Levy and Klemperer's Clinical Bacte- 
riology, 17 

Mallory and Wright — Pathological 

Technique, 18 

McFarland — Pathogenic Bacteria, . . 19 

CHARTS, DIET-LISTS, ETC. 

Griffith— Infant's Weight Chart, ... 14 

Hart — Diet in Sickness and in Health, . 15 

Keen — Operation Blank, 17 

Laine — Temperature Chart. . . . 17 

Meigs — Feeding in Early Infancy, . . 19 

Starr — Diets for Infants and Children, . 28 

Thomas — Diet-Lists, 30 

CHEMISTRY AND PHYSICS. 

Brockway — Essentials of Medical Phys- 
ics, . . 9 

Wolff — Essentials of Medical Chemistry, 31 

CHILDREN. 

An American Text-Book of Diseases 

of Children, . . 5 

Griffith — Care of the Baby, 14 

Griffith — Infant's Weight Chart, ... 14 

Meigs — Feeding in Early Infancy, . . 19 

Powell — Essentials of Dis. of Children, 21 

Starr — Diets for Infants and Children, . 28 

DIAGNOSIS. 

Cohen and Eshner — Essentials of Di- 
agnosis, 11 

Corwin — Physical Diagnosis, .... 11 

Macdonald — Surgical Diagnosis and 

Treatment, 18 

Vierordt — Medical Diagnosis, .... 31 

DICTIONARIES. 

Dorland — Pocket Dictionary, .... 12 

Keating — Pronouncing Dictionary, . . 16 

Morten — Nurse's Dictionary, .... 20 



EYE, EAR, NOSE, AND THROAT. 

An American Text- Book of Diseases 

of the Eye, Ear, Nose, and Throat, . 5 

De Schweinitz — Diseases of the Eye, . 12 

Gleason — Essentials of Dis. of the Ear, 13 

Jackson — Manual of Diseases of Eye, . 16 
Jackson and Gleason — Essentials of 

Diseases of the Eye, Nose, and Throat, 16 

Kyle — Diseases of the Nose and Throat, 17 



GENITO=URINARY. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 

Hyde and Montgomery — Syphilis and 
the Venereal Diseases, 

Martin — Essentials of Minor Surgery, 
Bandaging, and Venereal Diseases, . 

Saundby — Renal and Urinary Diseases, 

Senn — Genito- Urinary Tuberculosis, . 

Vecki — Sexual Impotence, 

GYNECOLOGY. 

American Text- Book of Gynecology, 
Cragin — Essentials of Gynecology 
Garrigues — Diseases of Women, 
Long — Syllabus of Gynecology, 
Penrose — Diseases of Women, . , 
Pryor — Pelvic Inflammations, . 
Sutton and Giles — Diseases of Women 



20 

34 
30 



MATERIA MEDICA, PHARMACOL- 
OGY, AND THERAPEUTICS. 

An American Text-Book of Applied 

Therapeutics, 5 

Butler — Text-Book of Materia Medica, 

Therapeutics and Pharmacology, ... 10 
Cerna — Notes on the Newer Remedies, 10 
Griffin — Materia Med. and Therapeutics, 14 
Morris — Essentials of Materia Medica 

and Therapeutics, . . 19 

Saunders' Pocket Medical Formulary, 26 
Sayre— Essentials of Pharmacy, ... 26 
Stevens — Essentials of Materia Medica 

and Therapeutics, ......... 28 

Stoney — Materia Medica for Nurses, . . 30 
Thornton — Dose-Book and Manual of 

Prescription-Writing, ....... 30 

MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

Chapman — Medical Jurisprudence and 
Toxicology, 10 

Semple — Essentials of Legal Medicine, 
Toxicology, and Hygiene, ..... 27 



Medical Publications of W. B. Saunders & Co. 



33 



NERVOUS AND MENTAL 
DISEASES, ETC. 

Burr — Nervous Diseases, 9 

Cbapin — Compendium of Insanity, . . 10 
Church and Peterson — Nervous and 

Mental Diseases, 10 

Shaw — Essentials of Nervous Diseases 

and Insanity, 28 

NURSING. 

Griffith— The Care of the Baby, ... 14 

Hampton — Nursing, . „ 14 

Hart — Diet in Sickness and in Health, 15 

Meigs — Feeding in Early Infancy, . . 19 

Morten — Nurse's Dictionary, .... 20 

Stoney — Materia Medica for Nurses, . . 30 

Stoney — Practical Points in Nursing, . 29 

Watson — Handbook for Nurses, ... ^51 



OBSTETRICS. 

An American Text-Book of Obstetrics 
Ashton — Essentials of Obstetrics, . 
Boisliniere — Obstetric Accidents, . 
Dorland — Manual of Obstetrics, . 
Hirst — Text-Book of Obstetrics, . 
Norris — Syllabus of Obstetrics, . . 

PATHOLOGY. 

An American Text-Book of Pathology, 

Mallory and Wright — Pathological 
Technique, 

Semple — Essentials of Pathology and 
Morbid Anatomy, 

Senn — Pathology and Surgical Treat- 
ment of Tumors, 

Stengel — Text-Book of Pathology, . . 

Warren — Surgical Pathology and Thera- 
peutics, 

PHYSIOLOGY. 

An American Text-Book of Physi- 
ology, 

Hare — Essentials of Physiology, . . . 
Raymond — Manual of Physiology, . . 
Stewart — Manual of Physiology, . . . 

PRACTICE OF MEDICINE. 

An American Text-Book of the The- 
ory and Practice of Medicine, .... 

An American Year-Book of Medicine 
and Surgery, 

Anders — Text-Book of the Practice of 
Medicine, 

Lockwood — Manual of the Practice of 
Medicine, 

Morris — Essentials of the Practice of 
Medicine, 

Stevens — Manual of the Practice of 
Medicine, 

SKIN AND VENEREAL. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 

Hyde and Montgomery — Syphilis and 
the Venereal Diseases, 



3i 



Martin — Essentials of Minor Surgery, 
Bandaging, and Venereal Diseases, . 18 

Pringle— Pictorial Atlas of Skin Dis- 
eases and Syphilitic Affections, ... 21 

Stelwagon— Essentials of Diseases of 
the Skin, 2 g 

SURGERY. 

An American Text-Book of Surgery, 7 
An American Year-Book of Medicine 

and Surgery, 8 

Beck — Fractures, 9 

Beck — Manual of Surgical Asepsis, . . 9 
DaCosta — Manual of Surgery, .... 12 
International Text-Book of Surgery, . 15 

Keen — Operation Blank, 17 

Keen — The Surgical Complications and 

Sequels of Typhoid Fever, 17 

Macdonald — Surgical Diagnosis and 

Treatment, 18 

Martin — Essentials of Minor Surgery, 

Bandaging, and Venereal Diseases, . 18 
Martin — Essentials of Surgery, .... 18 

Moore — Orthopedic Surgery, 19 

Nancrede — Principles of Surgery, . . 20 
Pye — Bandaging and Surgical Dressing, 21 
Scudder — Treatment of Fractures, . . 26 
Senn — Genito-Urinary Tuberculosis, . 27 

Senn — Syllabus of Surgery, 27 

Senn — Pathology and Surgical Treat- 
ment of Tumors, 27 

Warren — Surgical Pathology and Ther- 
apeutics, 31 

URINE AND URINARY DISEASES. 

Saundby — Renal and Urinary Diseases, 26 
Wolff — Essentials of Examination of 
Urine, 31 



MISCELLANEOUS. 

Abbott — Hygiene of Transmissible Dis- 
eases, 8 

Bastin — Laboratory Exercises in Bot- 
any, 9 

Gould and Pyle — Anomalies and Curi- 
osities of Medicine, 13 

Grafstrom — Massage, 14 

Keating — How to Examine for Life 

Insurance, 16 

Rowland and Hedley — Archives of 

the Roentgen Ray, 21 

Saunders' Medical Hand- Atlases, .2, 3, 4 
Saunders' New Series of Manuals, 24, 25 
Saunders' Pocket Medical Formulary, 26 
Saunders' Question-Compends, . . 22, 23 
Senn — Pathology and Surgical Treat- 
ment of Tumors, 27 

Stewart and Lawrance — Essentials of 

Medical Electricity, 29 

Thornton — Dose-Book and Manual of 

Prescription-Writing, . 30 

Van Valzah and Nisbet — Diseases of 
the Stomach, 3° 






no 



BOOKS JUST ISSUED. 

9 - 

THE AMERICAN ILLUSTRATED MEDICAL DICTIONARY. 

For Students and Practitioners. A Complete Dictionary of the Terms used in Medi- 
cine and the Allied Sciences, with a large number of Valuable Tables and Numerous 
Handsome Illustrations. Edited by W. A. Newman Dorland, M. D., Editor of the 
American Pocket Medical Dictionary. Handsome large octavo, 800 pages, bound in 
full limp leather, and printed on thin paper of the finest quality, forming a handy 
volume, only 1^ inches thick. 

This is an entirely new and unique work, intended to meet the need of practitioners and students for a 
complete, up-to-date dictionary of moderate price. The book is designed to furnish a maximum amount of 
matter in a minimum space and at the lowest possible cost. It contains double the material in the ordinary 
students' dictionary, and yet, by the use of a clear, condensed type and thin paper of the finest quality, is only 
1% inches in thickness. It is bound in full flexible leather, and is just the kind of a book that a man will want 
to keep on his desk for constant reference. The book makes a special feature of the newer words, and 
defines hundreds of important terms not to be found in any other dictionary. It is especially full in the 
matter of tables, containing more than a hundred of great practical value. A new feature is the inclusion 
of numerous handsome illustrations, many of them in colors, drawn and engraved specially for this book. 
These have been chosen with great care and add infinitely to the value of the work. The book will appeal 
to both practitioners and students, since, besides a complete vocabulary, it gives to the more important 
subjects extended consideration of an encyclopedic character. 

BOHM, DAVIDOFF, AND HUBER'S HISTOLOGY. 

A Text=Book of Human Histology. Including Microscopic Technic. By Dr. 
A. A. BiJHM and Dr. M. von Davidoff, of Munich, and G. C. Huber, M. D., 
Junior Professor of Anatomy and Histology, University of Michigan. 

FRIEDRICH AND CURTIS ON THE NOSE, THROAT, AND EAR. 

Rhinology, Laryngology, and Otology in their Relations to General 
Medicine. By Dr. E. P. Friedrich, of the University of Leipsig. Edited by 
H. Holbrook Curtis, M. D., Consulting Surgeon to the New York Nose and Throat 
Hospital. 

LEROY'S HISTOLOGY. 

The Essentials of Histology. By Louis Leroy, M.D., Professor of Histology 
and Pathology, Vanderbilt University, Nashville, Tennessee. 

OGDEN ON THE URINE. 

Clinical Examination of the Urine. By J. Bergen Ogden, M. D., Assistant 
in Chemistry, Harvard Medical School. Handsome octavo volume of over 408 pages, 
with 54 illustrations and I r full-page plates, many in colors. 

PYLE'S PERSONAL HYGIENE. 

A Manual of Personal Hygiene. Edited by Walter L. Pyle, M. D., Assist- 
ant Surgeon to Wills Eye Hospital, Philadelphia. Octavo volume of 344 pages, 
fully illustrated. 

SALINGER AND KALTEYER'S MODERN MEDICINE. 

Modern Medicine. By Julius L. Salinger, M. D., Demonstrator of Clinical 
Medicine, Jefferson Medical College, and F. J. Kalteyer, M. D., Assistant Demon- 
strator of Clinical Medicine, Jefferson Medical College. Handsome octavo volume of 
over 800 pages, fully illustrated. 

STONEY'S SURGICAL TECHNIC FOR NURSES. 

Surgical Technic for Nurses. By Emily A. M. Stoney, late Superintendent 
of the Training-School for Nurses, Carney Hospital, South Boston, Massachusetts. 



LIBRARY OF CONGRESS 



029 561 269 1 



